HomeMy Public PortalAbout4942 WILLMONTE AVE_Sewer__ �616AJ45 4'.^_D1D - ,APPLICATION FOR PERMIT
6
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
t DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 'BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
COLEMAN W. JENKINS, SUPT. OF BUILDING � f---
LOC ' "
ALITY
NEAREST
FOR APPLIC41NT TO FILL IN CROS5 . _
LEGAL
DESCRIPTION LOT NO K,--jry .-_y OWNER
MAIL
BLOCK TRACT •jk ADDRESS
NO. OF SLDGS-
SIZE OF LOT NOW ON LOT -- CITY TEL. NO.
USE OF
BUILDINGS _ DISTRICT NO. GROUP MAP ROCES D BY
PO
CONTRACTOR'.{
ADDRESS CONNECTION DATA
CITY s',. -r. TEL NO. STATION !4.; DEPTH I
STATE Y LIC-~- 4 RIUpP
LICENSE NO - MANHOLE REFERENCE 7 CLASS
NO. DESCR(P'TION_OF-WORK FEE - ---' �� --� LOWER
_ __ TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO I Y. CURB
PUBLIC SEWER _A . . —'
$S-DO PCNO.
SEPTICAN
TK,-S�EP
GE PIT OR -
PITS AND/OR DRAINFIELD _� E10.00 co,IMP_NO. F ,- JOB NO.H OU
NO—
PRIVATE
SEWER CONNECTING?O TRUNK PERMIT NO. w..-�^^"'"'""""`"'"ROAD PERMIT NO. _� d.
PRfVA7E CtSPOSAL SYSTEM C� $3.00 - CI
CCN NEC7 ADDITIONAL @LOG OR AFFIDAVIT wAIYEIi EASEMENT RECORD.INSTR.NQ. DATE
WORK TO HOUSE SEWER @ $3.00 I
OVERFLOW SEEPAGE PIT.DRAINFl.E LD.
EX7N..CESSPOOL.DRVWEL L.MANHOLE $9.00 HWY.QRST.WIDENING Ca
—.____ _-�."_ _
ALTER,REPAIR OR A@ANDON HOUSE ,.
I SEWER OR DISPOSAL SYSTEM - - --'----- uj
E3:00 +-- " STATE ENCROACHM NE 7
_-i__.. _-. __--_._..-_ _-.•y
PERMIT _—
NO.
--'-'"--- -- -- �-!----- INDUSTRIAL
�— WASTE APPROVAL r-- -''�"�""'""'•'�W
CHARGES- �—
OWNER'S PERMIT-----_ a� ZToo — —
AUTHORIZATION TOTAL FEE r r CONNECTION CHARGE FEL�..+�7 - - --
iHAVE AT THIS DATE A CONTRACT WITH THE HE NAMED CON- REIMBURSEMENT FEE
TRACTOR TO-CONNECT THE ABOVE DESCRIBED EXISTING DWELLING --- - ---------
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 1g_ ------ -- -------
OWNER OR NEW HOUSE SEWER
.OWNERS AGENT,_ CONNECT ADDITIONAL
ADDRESS
BUILDING OR WORK •'"."•"'. ....,-...,—___...,.._._..__,....
I
HEREBY ACKNOWLEDGE THAT,I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
ANDJ UR DRAINFIELD
AND S7A7E THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY .-..._— —,_�_
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT i AM PROPERLY REGISTERED AND/OR ALTER,REPAIR SEWER OR
1_IC ENSED AS REOWRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
GAL iFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESiOE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE'SEWER
SIGNATURE
,. f BACKFILL SEPTIC TANKS
OF PER MTTTEE `� ✓ �,gLS., a � SEEP,PITS) ❑ CESSPOOLS
---'VALIDATION JACK R. ALLEN
CK.
M.0. CASH SUPERVISING MECHANICAL ENGINEER