HomeMy Public PortalAbout9916 WOODRUFF AVE_Sewer__ '6A 642D -CE808-10-71 APPLICTION FOR WRMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEAREST
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FOR APPLICANT TO FILL IN T.
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LEGAL
DESCRIPTION LOT NO. . OWNER
MAIL ,r,..--.....
BLOCK _ TRACT _ _ -_ ADDRESS •+j`r�'~•
- NO. OF BLDG$.
SIZE OF LOT i NOW ON LOT CITY TEL. NO_. .,
USE OF
BUILDINGS DISTRICT NO. GROUP MAP —PROCESSED BY
BK PS
CONTRACTOR
ADDRESS ��4--- CONNECTION DATA
CITY
"r STATION
DEPTH
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STA LIC /'''� MANHOLE REFERENCE
LICENSE N41 ' R
it�t CLA59L ""�- ' s, LOWE
NO. DES�CFIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM - --
HOUSE SEWER CONNECTING TO - Y. 4URB— P.L. M.L.TO P.L. _
PUBLIC SEWER @ $7.00 - P,C.NO.
SEPTIC TANK.SEEPAGE PIT OR JOB NO.
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO JJ}}
PRIVATE DISPOSAL SYSTEM $3.00 d �,S
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wAIVEE I EASEMENT I RECORD. INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3-00 _
OVERFLOW SEEPAGE PIT.DRAINFIELD Of
E XTN..CESSPOOL.DRYWELL. @ $5.00 HWY,OR ST.WIDENING O
ALTER.REPAIR OR ABANDON HOUSE
.SEWER OR DISPOSAL SYSTEM _ Q $3.00 STATE ENCROACHMENT
MANHOLE _---- $7.00 PERMIT NO, d1 S' w
---- _---' INDUSTRIAL - N
WASTE APPROVAL Z
OWNER'S PERMIT s 3 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO.:CONNECT THE ABOVE DESCRIBED EXISTING DWELLING --- --
TO THEZA.El
IC SEWER. APPROVALS DATE I NSPECTOR'S SIGNATURE
SIGNE ,S DAY O�" 19_ -'
OW NEW HOUSE SEWEROWNER7� lr p y 'L"!i („L ,
1I`+ ? CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
1 HEREBY ACK NOWLED SEPTIC TANK,SEEP,PIT(S)
CSt THAT i HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND
STATE THAT THE ABdVE IS CORREC • AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL
I HEREBY CERTIFY T I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS RCVEDES
OS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR € LEGAL O R OF-AN INTEND TO `
RESIDE IN. THEIBED RES _IA PRO RTY. DISCONNECT PLUG AND
ABANDON HOUSE SEWER
SIGNATUREBACKFILLOF PERMrTTEE _ _.-- _..- CESSPOOLS f✓�� i u.���j ",,,y,l'
VALIDATION OK. M.0. CASH