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HomeMy Public PortalAbout9116 WOOLLEY ST_Sewer__ APPLICATION FOR PERMIT fl ION Of RU1LD!4G AND SAFETY SEWER--SEWAGE DISPOSAL. JDepmiment of Cmty Engineer 'ounty 3: LiY:s Angeles rAD DING ESSlrffii. i. �F'OX, � LNTY ENGINEER CASSA P D.GiRIFFIrv.SUPT OF BUILDING LITY FOR APPLICANT TO FILL IN NEAREST CROSS ST, LEGAL DESCRIPTION LOT NO.,�`�—�_�._..,. - - - OWNER BLOCK TRACT MAIL -- - _ - - ADDRESS `N0. OF 6LDGS, tl OW ON--LOT CITY TEL. NO. -.- -- USE OF - BUiLDINGS DISTRICT N0. -GROUP MA CONTRACTOR - BK PG ADDRESS —^_ CONNECTION DATA — CITY TEL. NO, STATION DEPTH D STATE IAI,HOLE REFERENCE LOWER REGISTRATION N0. © COUNTY UPPER _...._.._._ -` TYPE Of CONNECT O"' LENGTH FROM NO. DESCRIPTION OF WORK FEE �`._ _ C 'S_ P.L_. M.L. 70 P.L. H4U E SEWER CONNcCTING TO .. PUBLIC SEWER $�1.50 I HOUSE SEVER CONNECTING 1.0 PRIJATE DISPOSAL SYSTEM 1.00 j — --s-------- — CONNECT ADDITIONAL BLDG. OR — CO. IMP. NO. JOB. N0. --. WORK TO HOUSE SEWER t 00 -_ _ : iALTER OR REPAIR EXISTING SEW R OR DISPOSAL SYSTEM 1.00 �,._._ TRUNK PERMIT NO. ROAD PERMIT NO. DISCONNECT AND ABANDON SEWER AND/OR DISPOSAL SYSTEM 1.00 I ` STATE ENCROACHMENT } �ISEPTIC TANK SEEPAGE PIT OR _.� �--•-- _PERMIT 140.y n --_—,—•- ----------_—� PITS AND/OR DRAINFiELD 2.00 1 �I-- INDUSTRIAL I CESSPOOL DRYWELL— i WASTE APPROVAL I SPECIAL CC'NDITIONS ONLY 2.00 CHARGES CONNECTION CHARGE FEE. O"VNER'S PERMIT" --——3._I 00 AUTHORIZATION TOTAL. FEE 1 i I` REIMBURSEMENT FEE - I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMEDCON_ p� �+ TRACTOR TO CONNECT THE ABOVE CESC.RIgED EXISTING DKLT LINt APPROVALS DATE iNS E TOR'S SIGNATURE TO THE PUBLIC SEWER NEW HOUSE SEWER SIGNED THIS_____._._.......—.D.'1Y Or—__a.�_.._.�.��_.._.99..__-._ OWNER OR i-. CONNECT.ADDiTIONAL BUILDING OR WORK OWNERS AGENT--:..>__._-...�_._..-_-.__�__:x......_.____.�.�;._:..._�_. - --- .._ SEPTIC.TANK SEEP,PIT(S) _AND/O_RDRAINFIELD _ 1 HEREBY ACKNOWLEDGE THAT I HA.V:E READ THIS APPLICATION CESSPOOL 0 DRYWELL CT AND STATE THAT THE ABOVE IS CORRICT AND AGREE TO COMPLY .—.__._.—........_- WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM _ I IiEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND v LICENSED ASREQUIRED BY LOS ANGELES COUNTY AND TATE OF BANDON HOUSE SEWER CALIFORNIA IA OR THAT I AM THE LEGAL OWNER OF THE ABOVE .._.._N _. ..._._V. DESCRIBED RESIDENTIAL PROPERTY, BACKFILL SEPTIC TANKS SEEP.PITS) EI CE55POQLS fl "S1URE ." . `_ERMITTEE '- WILLIAM J.FOX,COUNTY ENGINEER VALIDATION t y B7 B DEPUTY . ."'. D*EPUTY DY BY iP; DEPUTY D-I P L'TY