HomeMy Public PortalAbout9142 WOOLLEY ST_Sewer__ :EB09 12-6e
FGA eazo APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING / ale
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JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS Y ( �i G
COLEMAN W. JENKINS, SUPT. OF BUILDING "—
LOCALITY
NEARE
CROSSSST. L• �
FOR APPLICANT TO FILL IN
LEGAL
DESCRIPTION LOT NO. �. OWNER y'I S
/p MAIL
BLOCK TRACT ! Y .f „) ADDRESS
NO. OF BLDG&. / '3
SIZE OF LOT NOW ON LOT / CITY TEL.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS J SK F-G /
1 �
CONTRACT - ,YL. -� ° � ` f "�-`� C � •
ADDRESS CONNECTION DATA
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I STATION = DEPTH
CIT
S E f LIC +y MANHOLE REFERENCE UPrP.wER�1[—
LICENSE NO. GLASS �^' G.� y am"
NO. DE`SCR7---_��OFW FEE TYPE OF CONNECTION .�•�""_. LEN H FROM
HOUSE SEWER CONNECTING TO �Q.�r Y. CURB _P.L- M.L. O P.L.
PUBLIC SEWER _ f_3_.00 -�+, C,! C+ — J. P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR ,• JOB NO.
PITS AND/OR DRAINFIELD $10.00 CO_IMP.NO.
HOUSE SEWER CONNECTING TO I TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00 __ __ __ O
CONNECT ADDlT10NAL BLDG.OR ,—� AFFIDAVIT MAIv[e uSEMCNT RECORD.IN5TR.NO. DATE U
WORK TO HOUSE SEWER $3.00 - —— �
OVERFLOW SEEPAGE PIT.DRAINFIELD ._—.___. -- — �
EXTN CE5SPOOL.ORYWELL.MANHOLE $5.00 _ ~
_�__ __.__—___--------------- --t HWY.O R ST.WIDENING
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1 ALTER.REPAIR OR ABANDON HOUSE I _ _ _. _— Ltd
SEWER OR DISPOSAL SYSTEM $3.00 I 6TATE ENCROACHMENT ---'— c-
--------- ---ttt--- PERMIT NO.
__f� --- --F---- INDUSTRIAL
J 1 WASTE APPROVAL _
OWN R'S PERMIT _ s"_ z', ,O��Gtyy0 - ------
AUTHORIZATION TOTAL FEE �� CONNECTION CHARGE FEE
' REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO,CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
_
TO THE PUBLIC SEWER.
SIGNED THIS Y OF r 3 " / 19� --T—-- -
OWNER OR AA �y..�A NEW HOUSE SEWER
OWNERS A EN —LC JJ 7f �� —�_ -_CONNECT ADD
l710NAL
BUILDING OR WORK
ADDP.ES _ _
_ � — ---- SEPTIC TANK.SEEP,P17(5)
I HERF.B �CK WLEDGE THAT 1 H VE READ THIS APPLICATION AND/OR DRAINFIELD
AND STA THAT 7HE ABOVE 15 CO ECT AND AGREE TO COMPLY -------
WITH ALL COUNTY ORDhNANCES AND STATE LAWS REGULATING CESSPOOL ❑ DRYWELL []
PLUMBING AND SEW ERS. ___—_— — ------
I HEREBY CERTIFY THAT I AM "OPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS R.EOUIRED BY LOS ANObL..ES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM _
CAL I FO RNIAR'THAT:'I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN H,}} AR.OVE DESCRIBED RESIDENTJAL PROPERTY. ABANDON HOUSE SEWER -
M� _e_ )
SIGNATU�'E ���; BACKFILL SEPTIC TANKS ❑
OF PEFt MTT'TE i.;—T—__.—Y f - SEEP.PIT(S) ❑ CESSPOOLS Cl
VALMATIONy_ JACK R. ALLEN
"T.. SUPERVISING MECHANICAL ENGINEER
CK. M.O. 'CASH - -