HomeMy Public PortalAbout9521 WEDGEWOOD ST_Sewer__ :EBOS 12-68 . APPLICATION FOR PERMIT
i6A 6420 - SEWER--SEWAGE DISPOSAL
COUNTY OF LOS ANGELES /
DEPARTMENT OF COUNTY ENGINEER BUILDING r' (`:�'s( cf'�l
BUILDING AND SAFETY DIVISION ADDRESS _
JOHN A. LAMBIE. COUNTY ENGINEER
LOC AIITY ✓�" ' '•
COLEMAN W. JENKINS. SUP-T. OF BUILDING LOCNEA LIr
GROSS ST.
FOR APPLICANT TO FILL IN
L GAL
OWNER LOT NO.
DESCRIPTIO_ MAIL .-.�r•.y .��, •) .
ADDRESSLi
BLOCK TRACT TEL. NO. T U_
7. � NO. OF SLOGS. CITY - e'
NOW ON LOT MAP PROCESS BY
512E OF LOT ' DISTRICT NO, G fCIU�p- BK PG t,
USE OF �J�� /c -✓
~ ✓1 J' ,.+� p /F
BUILDINGS (�f{ y «-._ V r (,.r - Lu
CONTRACTOR. l./{.- ..// CONNECTION DATA
DEPTH
ADDRESS STATION UPPER
TEL. NO.
CITYLIC MANHOLE REFERENCE LOWER
STATE CLASS - - LENGTH FROM
LICENSE NO. FEE TYPE OF CONNECTION P L M L TO P.L.
DESCRItjI OF WORK Y. CURB
NO.
HOUSE SEWER CONNECTING TO $5.00 JOB NO. >,•,
PU BIIC SEWER _ IMP.N0 _--- d
SEPTIC TANK,S EPA GE PIT OR :10.00 ROAD PERMIT NO. Q
OR DRAINFIELD_ ___ TRUNK PERMIT NO.
PITS AND/ _ -.--- U
HOUSE"SEWER CONNECTING TO _ - DATE
s3.00 -
PRIVATE DISPOSAL SYSTEM _-- - I w AFFIDAVIT WAIVER EASEM[NT I RECORD.1NSTR. O
CONNECT ADDITIONAL $3.00 _ ✓
i WORK TO MOUSE SEWE� __--_— �J
......111--------- OVERFLOW SEEPAGE PIT.DRAINFIELD
_. - -_-� - - -_- HW V.OR 6T.WIDENING -
EXTN..CESSPOOL.DRYWELL,MANHOLE� SS.00 {
ALTER.REPAIR OR ABANDON HOUSE $3_00 NO
STATEERMIT ENCROACHMENT + iIl •.�. '- __
P . 44f JJ
SEw ER OR DISPOSAL SYSTEM _—, /
_- -- - INDUSTRIAL
WASTE APPROVAL
C" ARGE
OV]rjg$•5
PER s I - 21 00 CONNECTION CHA GE FEE
}� }�T�/ �wL+ I � '
AUTHORIZATION TOTAL. FEE REIMBURSEMENT-FEE
—APP AI.S DATE PECTOR'S SIGNATURE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO_.CONNECT THEABOVE DESCRIBED EX16TING DWELLING _-
TO THE PUBLIC SEWER, OF 19
SIGNED THIS_.—__- DAY NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT._- BUILDING OR WORK i
SEPTIC TANK.SEEP.PIT IS) 1
AND/OR DRAINFIELD '-
i HEREBY ACKNOWLEDGE THAT I HAVE READ
THIS APPLICATION - _ _-_
AND STATE THAT THE ABOVE 16 CORRECT AND AGREE To COMPLY CESSPOOL ❑ DRYWEL.L ❑
WITH ALL COUNTY ORDINANCES AND STATE LAW' REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. �-----
SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ANO/OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER;OF, AND INTEND TO ABANDON HOUSE SEWER
RESIOE IN, TF'1^E RBi?VE DESCRIBED RESIDENT, PROPERTY. BACKFILL SEPTIC TANKS ❑
`t { / '- SEEP.PIT(S)E ❑ CESSPOOLS ❑
SIGNATURE { , ' ["_�.�--
OF PERMITTEE—, - JACK R. ALLEN
yVALIDATION SUPERVISING MECHANICAL ENGINEER
K.
' t J M.O. GASH
�j V N l