HomeMy Public PortalAbout9167 WOOLLEY ST_Sewer__ E-6D
3 E-663 FI.58
APPLICATION .FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER--SEWAGE DISPOSAL
Department of County Engineer
County of Lai Angeles BU(LD{NG -� F
JOHN A. LAMBIE, COUNTY ENGINEER ADDP,ESS
CASSATT D. GRIFFIN, SUPT OF BUILDING - LOCA
FOR APPLICANT TO FILL IN cftoss s .
LEGAL
DESCRIPTIONLOT NO. "--- _OWNER -_ J--
MAIL
BLOCKi TkACT ADll.RESS
N0,OF BLDGS. -
SIZE OF LOT NOW ON LOT — _A CBT TEL. N0.
USE OF _ - --- -- -- DISTRICT NO. GROUP MAP
11 IG
B.UILDiNGS
CONTRACTOR- ^fir $ s,•=y.�-- - ------..�-- - Al j- --
ADDRESS
-- _-- —CONNECTION DATA -- -- _
..CITY^ TEL. N0, ,O - STATION "` J DEPTH -
- —_
MANHOLE REFERENCE UPPER
MANHOLE
STATE
REGISTRATION N0. [] COUNTY
NO.. DESCR[FTCON OF WORK FEE TYPE OF CONNECTfp. ti, LENGTH FROM
PUBLIC h0U5E SEWER CONNECTING TO I i --��'^y Ye CURB P.L. M.L.,TU P.L.
_ y
SEWER - ---@ $-3.501- -- `�! -------___---�- _
SEPTIC TANK,SEEPAGE PIT OR
__--1-PITS AND/GR DRAINFIF'LD f` $.3.00 ..--- -
OVERFLOW SEEPAGE PIT,DRAINFIELD P C N0.
EkTN ,CESSPOOL,DRYWELL,MANHOLE Cu $ 2._00 t C_O,IINP NO. � JJB NC.
HOUSE SEWER CONNECTING TO
i PRIVATE DISPOSAL SYSTEM tar- $1,00 i DRUNK PERMIT N0. ROAD PERMIT NO.
ADDITIONAL
--+. - ---- --- _. - --.
�. CONNECT BLCG.---OR--- _- STATE ENCROACHN.ENT
WORK TO HOUSE SEVEP, R� $t.00 IERMIT NO
ALTER,REPAIR OR ABANDON HOUSE ,NDUSTR[AL
SEWER OR DISPOSAL SYSTEM (1 $1.00
- ___i.-— ------- -- ---.-..... ----- 'j--�------- ',HASTE APPROVAL
1 l CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT- --- _�. .1 00 -- — ---- ------ ---- ------ -
AUTHORIZATION TOTAL FEE -�) - ( - REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA` ED CON- APPROVALS I, D,4TE �INSPFCTOR'SS±G.NATURE
-------'-----------`- ----�-.� _-.__�--_.._.-__.. ._.-__._:-------
TRACTOR TO CONNECT THE ABOVE DESCRIBED EtIS'T1NG DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEINER- -
SIGNED THIS UAY F `. ,.�.19� CONNECT ADDITIONAL
74�OWNER OR F BUILDING OR WORK _-.__-----�-- %------------
0.1h'NERS AGENTAMI d
SEPT-IC TANK,SEEP,PITS) E
__AND10k DRAINF- i LD
ADDRESS "_ -- -- . --_--.._.____-I-`--_-__�..__-__.Y.___--_-_._..
1. HEREBY ACKNOWLEDGE THAT I HOE READ THIS APPLICATION
AND .STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSFOOL(� DR}WELL(
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING. ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 ASA PROPERLY REGISTERED A.NDWOR DISCONNECT PLUG AND- i ------__
LICENSED AS REQUIRED. BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER.
CALIFORNIA OR THAT 1 AM THE LEGAL. OWNER OF THE ABOVE - -----f- ---------
DESCRIBED RESKDENTI GPERTY. r BACKFILL SEPTIC TANKS ElSEEP.PIT f S) Ll CESSPOOLSu
SIGNATURE --- --- ---- -- ,.__�.
OF PERM±TTEE -
� i
IOHN A. LAMBIE,COUNTY ENGINEER VAL TION ROBERT A.WOOD,CHIEF PLBG, INSPECTOR
IDAT
CK. Id. O. CASH
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