HomeMy Public PortalAbout5625 WELLAND AVE_Sewer__ :E808 3-61
sA642Dsaz� PERMITAPPLICATION FOR
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRESS
JOHN A, LAMBIE. County Engineer
WILLIAM A. JENSEN, Supt of Building ?
LOCALITY
NEAREST
FOR APPLICANT TO FELL IN cRgs$ sr. '
LEGAL
f.
DESCRIPTION LOT N0. OWNER y l
BLOCK TRACT ! 7 NAI
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT IDI
ITY TEL, NO,
BUILDINGS
USE STRICT NO.[GROUP NAP P OCESSED BY
BK PG
CONTRACTOR ADDRESS cd r-Gg, CONNECTION ATA
CITY /. TEL.NO ` TATION DEPTH
ATEREGISTRATION Nq. / C COUNTMANHOLE REFERENCE UPPER
LOWER
NO. DESCRIPTION OF R FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROMSEPTIC TANK,SEEPAGE PIT OR . CURB P.L. N.L.TO P.L.
PITS AND/OR DRAINFIELD @ S3.00
OVERFLOW SEEPAGE PST,DRAINFIELD
EXTN„CESSPOOL. DRYWELL @ $2.00-
HOUSE SEWER CONNECTING TO P.C.NO. O
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO, JOB N0, V
CONNECT ADDITIONAL BLDG.OR �/ Cie
WORK TO HOUSE SEWER SLOO TRUNK PERMIT N0. ROAD PERMIT N
SEWER OR PAIR OR A ABANDON HOUSE @ $1.00 STATE ENCROACHMENT
PERMIT NO. V
INDUSTRIAL
WASTE APPROVAL
CHARGE z
OWNER`S PERMIT $ 2 00 CONNECTION RGE.FEE `'..
A■7�V li�Oili[+A'nON TOTAL FEE REIMBURSEMENT FEE
WITH THE HEEINAMED CN
TRACTOR TO CIONNECT THE ABOVEDATE ATDESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS®�_DA og S- NEW HOUSE SEWER
OWNER OR
OWNERS AGE -�a CONNECT ADDITIONAL
NT ��. ''' ''. BUILDING OR WORK _
ADDRESS-4: - r� ,,� SEPTIC TANK,SEEP.PIT(S)
AND/OR
DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE 'RJ ICATION
AND STATE THAT THE ABOVE IS. CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM TVE LEGAL OWN OF THE ABOVE
DESCRIBED IAL P TY, BACKFILL SEPTIC TANKS ❑
SIGNATOR. 's ''� SEEP.PIT(S) ❑ CESSPOOLS
V ALIDATION ROBERT A. WOOD
CK. Y.0, CASH SUPERVISING MECHANICAL ENGINEER
, . 5DEC 14 ci D 3.0 01
f% f