HomeMy Public PortalAbout5013 WILLMONTE AVE_Sewer__ ,BAsaa® APPLICATION FOR ERMIT
.ssos s-s9 COUNTY OF LOS ANGELES
SEER--SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ;
ADDRESS ,� s
JOHN A. LAMBIE. County Enqineer Z
C SATT D. GEWFIN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL --- w
DESCRIPTION LOT N0. ` - OWNER =
BLOCK TRACT MAIL
ADDRESS
NO.OF BLDGS. ;_,.
SIZE OF LOT t. -.. If NOW ON LOT CITY F i i'" TEL. NO. __>'
USE
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
d _ a'
BK PG
CONTRACTOR
ADDRESS CONNECTION DATA
CITY a ,"` TEL.NO. STATIONy
.. DEPTH —
"
REGISTRATIOSTATE MANHOLE REFERENCE ' / UPPER
=
NO. DEN NO.SCRIPTION OF WORK FEE COUNTY
HOUSE SEWER CONNECTING TO
PUBLIC SEWER CO) $3.00 Y i," �•'
SEPTIC TANK,SEEPAGE PIT OR — TYPE OF CONNECT104-- -`, LENGTH FROM '
PITS AND/OR DRAINFIELD C4? S3.00 Y. CURB, M.L.TO P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN,.CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO ��-.r -aitr P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.1MP.N0. JOB NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT N0.
ALTER.REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT �$ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION 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 'TOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF l9_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT 9UIL.DING OR WORK
ADDRESS 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 ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND 'STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS, SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY .LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT JAM E LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENT) FROPE,RTY BACKFILL SEPTIC TANKS l]
SIGNATUSEEP.
RE ��.
OF PERMITTEE. b= � '- �-
jALMATION ROBERT A. WOOD
CK ' H.O. CASH SUPERVISING MECHANICAL ENGINEER
1 'I/'