HomeMy Public PortalAbout4824 WILLMONTE AVE_Sewer__ 76A848,58 APPLICATION FOR PERMIT 1
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
CAI=TT D. G IFF'IN, Sup't of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL . a
DESCRIPTION LOT NO.'` - OWNER
BLOCK TRACT MAIL
_ ADDRESS
— NO.OF BLOCS,SIZE OF LOT NOW ON LOT CITY TEL.NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
CONTRACTOR ;_ t
ADDRESS ;ws X.AC® ECTION DATA
S t,
CITY OV tr3sT C , TEL NO.
/4 's STATION ""�' -6- �'' „E;. DEPTH
STATE . UPPER
REGIS'T'RATION NO, COUNTY MANHOLE REFERENCE
NO. + LIESCRi1'Tlt?N OF 1NbRK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Cts $3,00 -
TYPE OF CdNNEC7I0Ny 1 EL. TH FROM
SEPTIC TANK,SEEPAGE PIT OR L.
TO P.L.
PITS AND/OR DRAINFIELD @ $3.00 Y. CURB P.L,
OVERFLOW SEEPAGE PIT,DRATNFIELD -
EXTN.,CESSPOOL,DRYWELL,MANHOLE 0 $2.00
HOUSE SEWER CONNECTING TO $ P.C.NO.
PRIVATE DISPOSAL SYSTEM a $1.00 CO.IMP.N0. JOB N0.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT N0, ROAD PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM $1.00 _PERMIT N0,
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT B 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE ..- REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS_---DAY--DAY OF 19—_, NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT_ BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
ADDRESS..__ ,—.,..._.._.-^----�--i - _ AND/OR-DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
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 AM 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 THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESID£NTIA PROPERTY. j BACKFILL SEPTIC TANKS❑
SIGNATURE
"Y"1 SEEP,FIT(S) [] CESSPOOLS
OF PERMITTEE
off , VALIDATION-= ROBERT A.WOOD
Alt, r.tt« 'eASI3
SUPHRVISING MECHANICAL ENGINEER
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