HomeMy Public PortalAbout4851 WILLMONTE AVE_Sewer__ 24650 INSERTS
I _
CE8
f
S642D
7AAPPLICATION FOR PERMIT
�<2�
COUNTY OF LOS ANGELES SEWER--SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING *
ADDRESS' G9 �= t a
70Ii A. LAMBIE, County Engineer
WILLINAM A. JENSEN. Supt of Building LOCALITY �i� _.�,�� ✓ �' �r.
NEAREST
FOR APPLICANT TO FILL IN CRoss sr. ~d�' °�
LEGAL , ✓ �a
DESCRIPTION LOT N0. OWNER y - .t°e°` a°.,��"`'..,
BLOCK TRACT - <' MAIL
_ADDRESS
r _ O.OF BLDGS.
SIZE OF LOT:..° �g. s� NOW ON LOT CITY _ TEL. NO...
USE OF
BUILDINGS �..^ -'" DISTRICT NO. GROUP �g MAP PR¢SE$SED BY
PG
CONTRACTOR - .. e ',. y4. lye- ! r
ADDRESS � ¢ — CONNECTION DATA
CITY .�
..y g STATION ?-,.' ..) t DEPTH
3 �-F7E_.N0. b�" _ u .*
} [� STATE MANHOLE REFERENCE _ UpPEet '
REGISTRATION MOc. ❑ COUNTY t, ,.�.ya" ""3� k. -
�
I DESCRIPTION OF WORK FEE
HOUSE SF NER CONNECTING TO
_ PU L!C_S`'WER_ @ $3.00 TYPE OF CONNECTIO —'•. LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB ° P.L./ M.L.TO P.L. `
PIT$AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL DRYWELL @ $2.00
HOSE SF4'aER CONNECTING TO ` ! - P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO,IMP.NO. k+' } JOB N0.
CONNECT ADDITIONAL BLDG,OR eR 0
TRUNK PERMIT N0ROAD PER
-MIT HOUSE SEWER @ $1.00 . MIT N0. U
ALTs R, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT 0
SEWER OR DISPOSAL SYSTEM @ $1.00 _PERMIT NO, C
INDUSTRIAL
WASTE APPROVAL -
_ CHARGES
OWNERS PERMIT 2 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE '' REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF (9 r NEW HOUSE SEWER
OWNER OR All y""_ CONNECT ADDITIONAL �
OWNERS AGENT ZoT'`� BUILDING OR WORK
r SEPTIC TANK,SEEP.PIT(S)
ADDR'r"SS - AND/OR DRAINFIRLD
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 REPAIR,
S SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR {SEWAGE DISPECT OSAL AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL 0 $R OF THE ABOVE
DESCRIBED RESIDENTIAL P_.OPERTY. �. '" BACKFILL SEPTIC TANKS ❑
SIGNATURE -_ ,.✓rte __SEEP.PIT(S) ❑ CESSPOOLS
OF PERMITTE -.
�F VALIDATION ROBERT A. WOOD
j�CK. IC 0. CASH SUPERVISING MECHANICAL ENGINEER
5.0 -