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Home My Public Portal About5304 WELLAND AVE_Sewer__ ;�4'6A 642D - 0APPLICATIO808 - 9/73 11�1 1.OR MIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER FBUILDINGBUILDING AND SAFETY DIVISION f d'�: t ' `FOR APPLICANT TO FILL IN -7 _ LEGAL v r'7 � "(�/•iia/r'. f�-� ,d'` e/'�-��. DESCRIPTION LOT NO. OWNER _ MAIL [ P BLOCK TRACT ADDRESS 3 S NO. OF 8LDGS. J ,,<? o-. JF'' TEL. NO. SIZE OF LOT' NOW ON CITY LOT _ i USE OF - OtSTRICTNO. GROUP MAP PROCESSED BY BUILDINGS BK PS EONTRACTOR � / fix, •g f z. CONNECTION DATA ADDRESS DEPTH _ � Y STATION CITY TEL. NO. ,� 2_6 STATE ) ✓, �.�!'J LIC I`r q / MANHOLE REFERENCE 4-1' f,_ LOWER LICENSE NO: j ) / GLASS NO. DESCRIPTION OF WORK FEE. TYPE OF CONNECTIO LENGTH FROM HOUSE SEWER CONNECTING TO / Y. CURB P.L. M.L.TO P.L. PUBLIC SEWER 0 $7.00 {/ P.C.NO. SEPTIC TANK.SEEPAGE PIT OR CO.IMP NO .IOB NO. PITS AND/OR DRAINFIELD 510.00 HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL.SYSTEM @ $3.00 _ CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wAIY[[ [A[[Y[NT RECORD.INSTR.NO. DATE d WORK TO HOUSE SEWER $3.00 OVERFLOW SEEPAGE PIT.ORAINFIELO EXTN..CESSPOOL.DRY WELL-____,.-o 33._00 HWY,OR ST.WIDENING Ind ALTER.REPAIR OR ABANDON HOUSE O SEWER O_R DISPOSAL_SYSTEM @ 3.00 _ STATE ENCROACHMENT PERMIT N0. LLI MANHOLE 4 $7.00 --- - a' _ INDUSTRIAL V9 WASTE APPROVAL Z _ CHARGES OWNER'S PERMIT f CONNECTION CHARGE FEE AUTHORIZATION I TOTAL FEE 4A-1---__ REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TAPPRDATE INSPECTOR'S SIGNATURE TO THE PUBO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING LIC SEWER. OVALS SIGNED THIS DAY OF 19_ ' NEW HOUSE SEWER OWNER OR OWNERS AGENT CONNECT ADDITIONAL BUILDING OR WORK SEPTIC TANK,SEEP,PIT(S) 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINF'IELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY — -� WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CESSPOOL ❑ DRYWELL ❑ PLUM g ING AND SEWERS. - 1 HEREBY CERTIFY THAT i AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFC',RNIA OR THAT (--AyM THE�EGAL OWNER OF, AND INTEND TO DI SCONNEC7 PLUG AND RESIDE IN. THE ASIVE�OESCRy ED RE61DEI�+IAL PROPERTY. ABANDON HOUSE SEWER SIGNATURE .' �d{�' f��.�' � %'"�� BACKFILL SEPTIC.TAN•KS OF PEOMffTEE SEEP.PITS)..3~ CESSP0 LS ❑ VALIDATION CK M.O. CASH r' 6A 642D - CE008 - 9/73 0 1, APPLICA" ON FOR RMIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER Ili BUILDING AND SAFETY DIVISION BUILDING FA.-RE LOCALITY NEAREST Z� FOR APPLICANT TO FILL IN CROSS ST. LEGAL A4 DES fx, ""'y cRiPrioN LOT NO. I NER MAIL BLOCK TRACT ADDRESS i NO. OFBLDGS. SIZE OF LOT NOW ON LOT CITY TEL, NO. USE OF _A4Qc_E BUILDINGS DISTRICT NO,. GROUP I S K M AP $sED BY ps irk' k CONTRACTOR ADDRESS CONNECTION DATA STATION DEPTH CITY TEL- NO. dd 46 STATE LIC UPPER LICENSE NOMANHOLE REFERENCE CLASS NO, DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM HOUSE SEWER CONNECTING TO V Y. M.L. CURB <L. 'l TO P.L: PUBLIC SEWER PIC.NO. SEPTIC TANK,SEEPAGE PIT OR JOB NO. Noi C - I J PITS A OR DRAINFIELD @ $10.00 O�IMP,NO, 3 -_ HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM @ $3.00 CON NEC'fAOr>li:!ONXL BLDG.OR AFFIDAVIT RECORD.INSTR.NO. DATE WORK TO HOUSE SEWER 0 S3.00 OVERFLOW-SEEPAGE-PIT,DRAINFIFLO C=1 EXTN_CESSPOOL.DRYWELL, $5.00 C-:p ALTER.REPAIR R OR ABANDON HOUSE HWY.OR ST.WIDENING SEWER OR DISPOSAL SYSTEM $3.00 C:) STATE ENCROACHMENT MANHOLE PERMIT NO, 0 $7,00LjJ INDUSTRIAL WASTE APPROVAL O S 3 ___C.AR... 3 I 1 �4 CONNECTION CHARGE FEE AUTHORIZATION--i TOTAL FEE WNER'S PERMIT I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR To CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. APPROVAlS DATE INSPECTOR'S SIGNATURE SIGNED THIS-DAY OF, _19- OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL ADDRESS BUILDING OR WORK SEPTIC TANK,SEEP,PIT(S) I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR GRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. RS. CESSPOOL [I DRYWELL 0 ID HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR LICENSEAS REGUZRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE.DISPOSAL SYSTEM rALI FC�a NIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABO'VLE BED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER SIGNATYRE y :,ACpK.FplLL'SFPTIC Or PEIRMtTTEE' TAN IT El Imll-so"Cas C] VALIDATION CK. M.0. CASH I. U