HomeMy Public PortalAbout4908 WILLMONTE AVE_Sewer__ 24650 INSCRTS
CEsoa€.60
76A642.D APPLICATION FOR PERMIT 4
COUNTY OF LOS ANGELES SEWER--SEWAGE' DISPOSAL` �
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDNG
ADDRESS ASS
12WH A. LAl'Tl E. County Enggineer
WYLLIAM A JE�ISF.N. Supt of Building LOCALITY � '�✓Y
NEAREST
FOR APPLICANT TO FILL yIN CROSS Sr.
DESCRIPTION I1aN LOl No. OWNER c
BLOCK TRACT MAIL
y� r ADDRESS
NO,OF
S)ZE OF LOT 1 ,f4 NOW ON LOTS CITY TEL. NO.
USE j pIJ DISTRICT NO. GROUP IAP PROCESS&A'BY
_BUILDINGS K'K� T" `I BK P� _
CONTRACTOR -
ADDRESS CONNECTION DATA
CITY T'EL.NO.�j'/ } �,,� STATION .- _. �'' �' DEPTH - _
R 'RATIO NO.J .rgF COUNTY MANHOLE REFERE_kCE ✓-� ,s ,,1'.' ' � UPPER
__ .s ♦d.. i NO. DESCR[PTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Ca $�.00 I4� TYPE OF CONNECTION - LENGTH FROM4 J
SE.e'iit:'TAivK:SEEPAGE PIT
Y. CURB - P L,! M.L.TO P,.
PITS ANDIOR DRAINFIELD C? $��.00
OVERFLOW SEEPAGE PIT, DRAINFIELD _.�.
EXTN..CESSPOOL DRYWELL C`y J .00
HOUSE SEWER CONNECTING TO ': r. - P.C.NO.
PRIVATE DISPOSAL SYSTEM Ll :1.00 CO.IMP. NO. F,'.* JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0. p
WORK TO HOUSE SEWER @,"S1.00 C
fLTER, REPAIR OR ABANDONHOUSE _ -
SEWER OR DISPOSAL SYSTEM @ I.00 STATE ENCf2pACNM'ENT
PERMIT N0, ---- _. - O
1NDUSTRIAI. _
- WASTE APPROVAL w
_
---,---CHARGES -
O 3ER'S PERMIT _ pQ CONN"TH)WCHARGE FEE
AUTHORIZATION TOTAL PEE EI �21) REIMBURSEMENT FEE
I HAVE. AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE I INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. ��--- -
SIGNED THIS DAY OF19— NEW HOUSE SEWER
OWNER OR > �e CONNECT ADDITIONAL
OWNERS AGENT. -- BUILDING OR WORK
ADDRESS.__ r SEPTIC TANK,SEEP.PITS)
----- — 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,SF.W'cR 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 kND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL, OWNER OF THE. ABOVE -.
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS []
SIGNATURE ' SEEP..PIT(S) Cl CESSPOOLS (3
OF PERMITTE
DF VALIDATION,—--,, (ROBERT A. WOOD.
BK. M.o. `CASH i SUPERVISING MECHANICAL ENGINEER
r -
���-�"tom y
Q� ALG
7