HomeMy Public PortalAbout5025 WILLMONTE AVE_Sewer__ 24650 INSERTS
76A06421) APPLICATIONFOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
DRESS -�
AD
I HN A. LAMBIE, County Enggineer
4VII.LIAM A. JENSEN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL ; OWNER
DESCRIPTION LOT N0. _
BLOCK TRACT .,
MAIL
--ADDRESS
NO,OT"BLDGS. 1 t
SIZE OF LOT NOW ON LOT ° CITY + C: r TEL. NO.
OF
BUI DI DISTRICT N0. GROUP MAP PROCESSED.BY
BUILDINGS
e n 4 r a L BK PG
caraTRAc7DR
ADDRESS Ory j J" CONNECTION DATA
CITY dls q,t 9 .>-- TEL.NO. w .^ '� STATION ._ - r.�' ,1'' . r/ DEPTHT.
- -
REGISTRATION NO. I .gfyV.� � � STRTEY MANHOLE REFERENCE '
t, � LOWER
NO. DESCRIPTION OF WORK FEE
HOUSESEWER CONNECTING TO
PUBLIC SEWER ; C 33.00 % TYPE OF CONNECTIQK-" LE14GTH F OM
SEPT!,'TANK,SEEPAGE PIT OR 4 Y. CURBF L. M.L.TO P.L.
PITS AND/ORDRAINFIELD
OVERFLOW SEEPAGE PIT.DP.AINFiELD
EXTN..CESSPOOL. DRYWELL CO $2.0�) .
HOUSE SEWER CONNECTING TO P.C.N0,
PRIVATE.DISPOSAL SYSTEM @ $1..00 CO.IMP NO. .JOB NO. �
CONNECT ADDITIONAL BLDG.OkTRUNK PERMIT N0ROAD PERMIT N0
WORK TO HOUSE SEWER @ $1.00 . 0.
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT 1:4SEWER OR DISPOSAL SYSTEM @ $1.00. PEP.MIT Nfl. - p
�- INDUSTRIAL - U
WASTE APPROVAL W
CHARGES
OVME'ER'S PERMIT 201 0CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH.THE HEREIN NAMED CON-
TRACTOR TO CONNECT T14E ABOVE DESCRIBED EXISTING DWELLING APPROVALS R'S SIGNATURE
TO THE PUBLIC SEWER. �—
SIGNED THIS - 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT. BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS .� h �v _ AND/OR D+RAMFiELD
J
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AN STATE TAWS REGULATING ALTER,REPAIR.SEWER OR
PLUM 1 ING ND SEWERS. SEWAGE DISPOSAL SYSTEM
t'tf{EREY CERTIFY THAT 1 AM PROP RI_Y GINE AND/OR DISCONNECT PLUG AND
LSCfC10IR
5 REQUIRED NG S C NT1�� .ATE OF ABANDON HOUSE SEWER
''CAlfA THAT A.A TH AL NES' T ABOVE ABANDON SEPTIC EWER D RES ENTI PF ERSIG % SEFP.PITS) ❑ CESSPOOLS ❑FTTE
F �' VALII?ATI®N ROBERT A. WOOD
S CC.i M.0. CASH SUPERVISING MECHANICAL ENGINEER