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HomeMy Public PortalAbout5620 WELLAND AVE_Sewer__ `AY°_ APPLICATION FOR PERMIT �� t ,�A64z� r N T OF COs Fs DEPARTMENTCOUNTY OF COUNTY ENGINEER SEWER- SEWAGE DISPOSAL BUILDING AND SAFETY DIVISION BUILDING SOHN A. LAMBI,E, County Engineer A�Da;sS WILLIAM A. TENSEN, Supt of Building -- - -- LOCALITY N BARESTFOR APPLICANT TO FILL IN Ross s r - - _._iernl -._. DESa RIF', CSN LUT NO. OWNER MAIL �� ;tv. BLOCY_ --_TRACT.. `,, ADDRESS NO OF BL:,G S. F.: OF LOT N'CW ON LOT CITY' TEL. NO. us OF BU,�_OI TAGS DISTRICT NO, GROUP MAP P. ROCESSED BY CONTRACTOR ADDRESS CONNECTION-DATA CITY TE;- STATION DEPTH REGISTRATION NO STAT£. MANHOLE REFERENCE UPPER `._ d - 1-�.JY_.. _— � COUN.7Y -., �,,,•"' r'.,. ,:,,. 4:'��YL:_. �g�qaq V NO.� DESCRIPTION OF VvORK FEE -- ---- _- LENGTH TYPE OF CA^7NtP770N L£NGYH I�ftOM :_..: �' , HOUSE SEWER CONNECTING 70 �. 'CU RB P.L. M.L.r0 P.L. ' PUB IC SEWERPC NO PITSA .— SEPTIC-YANK PAIE PFT, OR CO.IMP NO JOB NO. t+tD/OR DRAINFNFIIELD � 590.00 , 11 OU4E.SEWER CONPJEC'T fNG TO j TRUNK F ERMIT le O. ROAD PERMIT NO. U PRIVATE DISPOSAL SYSTEM @ S3.00 ._____ ._—.__. ..5. COPiNE:C7 ADD.7iONA C.L:TG OR AFFIDAVIT WAIVER� LASENENT T RECORD. INSTFt NO. "L:iATE rjE WORK TO HOUSE.SEWER @ %3.00 1 ._� _ —__..--.�— ....__ I.____.... z j OV£RF LOW SEEPAGE PIT',DRAiNP1ELD I EXTN.,C ES5POOL,DRYW ELL:MANFiOLE'@ $a5.OU .ASTER.REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING SEWER OR DISPOSAL SSTEM '� � #3.00 � --. -_.-- Y__.... __. _0M $30STATE ENCROACHMENT PERM I NO. INDUSTRIAL WASTF.APPROVAL CHARGES OWNER"R hFIdI�IIT z. ®o CONNECTION'CHARGE.PETE AUTHORIZATION TOTAL FES ------ --- ------ ------ — - — IHAVE- AT THIS DATE A CONTRACT WiYH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO C<""r T THE ABOVE OPSCR)BEL` EXISTING DW CLING -- -- -�-- --r—-- --- ----- TO THE" PU.bLIC £V+,EP APPROVALS DATE j INSPECTOR'S SIGNATURE SIGNED 'iH6 C>AY OWNER OR _ F NEW HOUSE SEWER OWNS S AGENT _.; CONNECT ADDITIONAL � --- -) —_-- -- '. Su ILDI NG OR WORK SEPTIC TANK,SEEP,PIT-(3) 1 HE.Fit9Y' ACKNOWLEDGE THAT I HAVE READ THIS APPi II A710N' AND�OR DRAtNF1ELD AND STAF. THATTHE ABOVE IS AND AGREE TO COMPLY WITH ALL COIj , ORDINANCES AND STATE LAWS REGULATING ALI;MB NG AND SE.W.ER.S. CESSPOOL �]. DRYW'ELL (� i NEREBY CERTIFY THAT f AM P'ROPF.RL REGiS.F_RED AND/OR A TER,RLPAf R,SLW£EOR i LICENSED AS REQUIRED BY LO ANGLES CO' N'Y`e AND STATE OF SE WAGE DISPOSAL SYSTEM j CkLIFORN IA OR 'THAT i AM THE LEGAL CiNNER OF', AND ANTE.PJD TO RESIDE IN, THE ABµ"VE nrUCRISED Rf,S L^lTlhd PROPERTY. DISCONNECT NIS"ODCN HT PLUG AND _ OUSE SEWER SIGNATURE SEPTIC TANKS BA —� OF PERM17.TLr" BACKFILL SEEP,PIT(S) 0 CESSPOO.LSS Of VALIDATION ROBERT A. WOOD e CK, SUPERVISING MECHANICAL ENGINEER M.O. CASH