HomeMy Public PortalAbout5008 WILLMONTE AVE_Sewer__ E$0$ 5-65
6A 6420 APPLIC ISN FORFEVWER-SEWAGE_PJSP0SAL
MIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION H.IL.IN
1011NA, ANBtF�' CcEngineer
unty ADORES
I
C: � 0 l
COLEMAN R JF.\KINS Supt. u: Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS
DESCRIPTION LOTNO ,t. Z/ _ OWNER
MAIL
BLOCK TRACT l/ 1 _L _L ADDRESS_
SIZE OF LOT
NO: OF BLDG S.
NOW 01LOT CITY Ls�..L+' f. TEL. NO.
USE OF —_—._
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
-'r�r
BK PC;
CONTRACTOR -
ADD s _ _CONECTION DATA _
JE N /. ) % STATION � .,�3 J . � � DEPTH
LICENSE !!CENSE
NO. CLA 55 MANHOLE REFERENCE N LESCRI PTION OF WORK FEE -TYPE OF CONNECTION 'LENGTH
fjR—OM V �
HOUSE SEWER CONNECTING TO —/;� Y. CURB P.L, M.L.TOyF'.L.
PUBLIC SEWER ^ $ 5.00 '`I t`(. _ -` _
F'T LIC TANK, SE EDGE PIT OR - (.r P.C,NO.
IT AND'OR DRAINFIELD - $1.0.00 _ CO. IMP, NO. JOB NO. Q
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. I J
PRIVATE DISPOSAL SYSTEM, $ 3.001
CONNECT ADDITIONAL SLOG OR + I AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE w
WORK TO HOUSE SEWER = $ 3.00
'A LT�R,REPkIT
SEWER OR DISPOSAL SYSTE'A $ 3.00I W
pyERFP'-U
�-SErr-A,GE-PTT_ R-AT}�FTT'[y----*— HWY. OR ST.WIDENING LLJ
E%TN. CE55 P00_, MANHOLE $ 5.00, STATE ENCROACHMENT
I PERCOLATION TEST (y, $ 5.OLi PERMIT NO. Z
_--'— ---'----' T�'-- INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S i PERMIT z o_o --
AUTHORIZATION TOTAL, FEE i Y CONNECTION CHARGE FEE —
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO. CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THISOF ---
OWNER OR NEW HOUSE SEWEROWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS___
SEPTIC TANK.SEEP,PITS)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO
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
LICENSFD AS REQUIRED BY LOS ANGLES CO NT'/ AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA O T i AM TH LEGAL O' NE OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE !N, F_ A OYE DES EO RE DE IAL PROPER T ABANDON HOUSE SEWER
'C KFILL SEPTIC.TANKS ❑
-- — -"- SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATION
CK. M.O. CASH