HomeMy Public PortalAbout5623 1/2 WELLAND AVE_Sewer__ 95A842b APPLICATION FOR PERMIT
Ca'8U8-73.58 � -
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDINGDRESS
JOHN A. LAMBIE, County Engineer
CASSATT D. GRIFFIN, Supt of Building LOCALITY �t _
FOR APPLICANT TO FILL IN `CROSS ST.
FDE
L � � ,
DESCRIPTION LOT NO. OWNER ;It',.
TRACT MAIL
! ' ' ADDRESS
NO OF BLDGS. ,�••�
OT NOW ON LOT CITY TEL.NO.
S DISTRICT NO. GROUP MAP PROCESSED BY
BK PC
TOR � ..: CONNECTIONDATAV�'_, t, y" TEL.NO. > ,, '„ �. STATION DEPTH
STATE UPPER
REGISTRRTION N0. I :, ' COUNTY MANHOLE REFERENCE —
no. DF_SCRIPTION OF WORK FEE LOWER
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PITS AND/OR DRAINFIELD @ $3.00 Y. CURB P.L. A.L.TO P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN„CESSPOOL,DRYWELL,MANHOLE 0 $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. JOB NO.
CONNECT ADDITIONAL BLDG.44-
O HOUSE SEWER $1:QQ w TRUNK PERMIT N0. ROAD PERMIT NO.
ALTER., REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM $1.00 PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
CHARGES
® R's PERMIT $ t. ® CONNECTION CHARGE FEF,
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE ' ` '
I NAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE' 3NSPECTOR S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS-------DAY OP I9� NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL ;
OW14ERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 1S CORRECT AND AGREE TO COMPLY CESSPOOL® DRYWELL 0
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM:
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
Ck IFORNiA OR H T I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED REST VIAL P,ROPE 9 BACKFILL SEPTIC TANKS C]
SIGNATURE SEEP.PIT
IST D CESSPOOLS El
OF PERMITTEE
VALIDATION ROBERT A.WOOD
SUPERVISING MECHANICAL.ENGINEER
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