HomeMy Public PortalAbout5012 WILLMONTE AVE_Sewer__ Esos 8.59k APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 4
ADDRESS
JOHN A. LAMBIE, Count�p En unser _ R
CASSATT �. GRIFFIN, Supt ei Building LOCALITY
NEAREST Ty
FOR APPLICMT TO FILL Icy CROSS ST. ; , ; =g y f
LEGAL y" b
DESCRIPTION LOT NO. OWNER -� _s JJ , e 1
BLOCK TRACT � MAIL .- �„ ,. r
ADDRESS f t o1 o- 4
gg j y OF BLDGS.
SIZE v d W ON LOT CITY TEL. NO. (•: s¢f
USE OF _. �
BUILDINGS - a' ° " +° DISTRICT NO. GROUP MAP BY
CONTRACTOR
8K PG
ADDRESS`- t CONNECTION DATA
CITY TEL.N0. STATION D'EFiH
REGISTRATION N0. � /� 'COUNTY MANHOLE REFERENCE UPPER
NO. DESCRIPTION OF WORK FLEE
HOUSE SEWER.CONNECTING TO
PUBLIC SEWER C" $3.00
TYPE OF CONNECTION, LENGTH FROM
SEPTIC TANK.SEEPAGE PIT OR Y. CURB P:L. M,L_TO P.L.
PITS AND/OR DR_A1NF'IELD $3.00
OVERFLOW SEEPAGE PIT,DRAMFIELD
EXTN.,CESSPOOL,DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO - P.C.NO.
PRVVATE DISPOSAL SYSTEM @ $1.00 CO,IMP. NO, JOB NO. -
CONNECT ADDITIONAL BLDG,OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER o $i.00 _
ALTER.REPAIR UR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DiSPUSAt SYSTEM i? $1
.00
PERMIT_ NU.
INDUSTRIAL
WASTE APPROVAL
CHARGES
Ommm'S PERMIT S . 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL.FEE I
- 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 QF - 19_ _ NEW HOUSE SEWER
OWNER OR "`+ ,.
CONNECT ADDITIONAL �
OWNERS AGENT BUILDING OR WORK
ADDRESS g- SEPTIC TANK,SEEP.PIT(S)
-- - AND/OR DRAINFIELD
i HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL LI DRYWELL. [I
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, -
PLUMBINGSEWER OR
AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERT9FY' THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
_
CALIFO�,hill4OR THAT 1 AM THE LEGAL OWNZR OF THE ABOVE —
DESCRIB D �ESI7JEaNTIAL PROPERT S BACKFILL SEPTIC TANKS ❑
SIGNATURE
tl d, SEEP.PIT(S) [] CESSPOOLs
�.
OF PERMITTEE -" = "
YALIDATION ROBERT A. WOOD
(I CK. :' N.o. CASH SUPERVISING MECHANICAL ENGINEER
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