HomeMy Public PortalAbout9110 WOOLLEY ST_Sewer__ IIT
BA
E86808 8-59 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE, County Engineer
CASSATT D. GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT N0. � - OWNER
BLOCK TRACT `y f MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO. - 4C-
USE OF ` t
BUILDINGS 4 s rT. `,/ DISTRICT NO. GROUP!. MAP PROSCESSED BY
BK PG
CONTRACTOR
ADDRESS CONNECTION DATA
CITY/ � TEL.NO., },
REGISTRATIOp!N0. -��/ STATION DEPTH
,,r ,,i,✓ `—LOWER
TATE MANHOLE REFERENCE. �'-LOWER`R
—
y` �?°`y` Lj COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER TYPE OF CONNECTION- { LENGTH FROM
SEPTIC TANK,SEEPAGE.PIT OR I 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.N0,
PRIVATE DISPOSAL SYSTEM @ $1.00 Co.IMP. N0. JOB NO,
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER Ia $1.00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE r 60 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMEDCON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPLCTOR'S.SIGNATURE
7'0 THE PUBLIC SEVIER _
SIGNED THIS , nAY OF J .>;_&; 99 NEW HOUSE SEWER
OWNER OR
AGENT / - ', `' ' f /1 _CONNECT ADDITIONAL
OWNERS
`J�,' r r.. - c- '� f d- '.t-� _BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS - ".�°f ...rte._..`. -;.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
I 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 THA `I AM TWE LEGAL OF THE ABOVE ---
DESCRIBED RESIDE 'AL)PROPERT y. BACKFILL SEPTIC TANKS ❑
SIGNATURE
JJ!✓ SEEP.PIT(S) 0 CESSPOOLS ❑
OF PERMITTE€
)r _-VALIDATION ROBERT A. WOOD
C& U.o, CASH SUPERVISING MECHANICAL ENGINEER
iso cY P 4r t `v
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