HomeMy Public PortalAbout5016 WILLMONTE AVE_Sewer__ 'EASAED - APPLICATION FOR PERMIT
.$808 8.89
COUNTY OF LOS ANGELES SEWER---SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE, County Engiassr ADDRESS ✓ �'' x}'
CASSATT D. GRIFFIN, Supt of Building LOCALITY sr
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. -,
LEGAL
DESCRIPTION ..CO`'-N - OWNER
BLOCKJMAIL r' ( ADDRESS '.
tt� OF BLDGS. 1 ' 3 +*
SIZE OF - r ( {rl WON LOS CITY TEL. NO. sp
USE OF
BUILDINGS DISTRICI GROUP MAP PG PROCESSED BY
6K
CONTRACTORv�`� y fi
ADDRESS -�fa` — CONNECTION DATA —
CITY .F w' TEL.NO. b / STATION LEPTD3
STATE MANHOLE REFERENCE _ UPPER`
REGISTRATION NO. -,l `S COUNTY LOyyEtg
NO. I DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00
TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3,00 -
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.. CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NOS, JOB NO.
CONNECT ADDITIONAL BLDG,OR $i.00 TRUNK PERMIT NO, ROAD PERMIT NO.
_ WORK TO HOUSE SEWER (�
IALTER,REPAIR OR ABANDONEM HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTCa $I,00 PERMIT NO,
INDUSTRIAL
WASTE:APPROVAL
CHARGES
OWNF.WS 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 I DATE �:NSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 15..® NEW HOUSE SEWER
OWNER OR I
NNECT ADDITIONALOWNERS AGENT V _COBUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS_— -- AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AFFLICAT'[ON
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL, ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS R.ECULATING ALTER,REPA[R,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT DISPOSAL
AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON DISCHOUSONNECT
CALIFORNIA OR THAT 1 AM r LEGAL, WNER OF Tf ABOVE
SEWER
DESCRIB£IX RESIDENFIAL PROPS e" �;` BACKFILL SEPTIC TANKS Q
SIGNATURE SEEP.PIT(S) Q CESSPOOLS ❑
O.F PERMITTE
P
'VALIDATION ROBERT A. WOOD
/'C H.o, CASH SUPERVISING MECHANICAL. ENGINEER
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