HomeMy Public PortalAbout9630 WOOLLEY ST_Sewer__ 7GA6420
E-663 51.86 APPLICATION FOR PERMIT
5&E•66 --
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING + , .
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS �� d✓� i� }% w�'
CASSATT D. GRIFFIN, SUPT OF BUILDINGion
LOCALITY-r
NEAREST
FOR APPLICANT TO FILL IN cRoss sT.
LEGAL ----
'� 1
DESCRIPTION LOT NO. vy
` a OWNER
a _. - L. ke f f tf- f ,t R -M '� .-• ----
BLOCK TRACT
Ii „[ `. _�+ .., ACDRESS
--� —NO. OF BLDGS.W ON LOT.
SIZE OF
LOT .,} (-yy^"r. NOf CITY � .` 's' TEL. NO. b -
--- `-- �d _�---3 -a.4-r- - .
�V
USE OF y
DUILDINGS oy,/ y t ,,rg�. — �\ DISTRICT NO, + GROUP - MAP
SK PGF
CONTRACTOR
CONNECTION DATA —
ADDRESS
STATION I ' DEPTH c -
CiTY ay... .4 TEL. N0. }-. ., ,+ - --= --- — -- --
`. .0 .MANHOLE REFERENCE F+
-- - 0--STATE lu'4 �. LOWER
REGISTRATION NO. ! ❑ COUNTY
NO. I DESCRIPTION OF WORK FEE ------ — ------ - --
--F - - -- - ----- - TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO -� I - Y. CURB P L M.L.TO P.L. I
PUBLIC SEWER C._ _ — $3.50 ---- ----
SEPTIC TANK,SEEPAGE PIT OR
_�. $3.00 PITS AND/OR DRAINFIELD - _ Cdr
I OVERFLOW SEEPAGE P11,DRAINFIELD P r N0.
EXTN„CESSPOOL.DRYWELL,MANHOLE La) $2.00 ---
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM {[r,. $1.00_ j _ TRUNK PERMIT NO. -_ -_— ROAD PERMIT NO__�i -
-� CONNECT ADDITIONAL
G.OP. � �
i jSTATE ENCROACHMENT
I WORK TO HOUSE SEALER _Ci$1.00 _PERMIT N0,_ -
--� ALTER,REPAIR OR ABANDON HOUSE --�-�1—� INDUSTRIAL ---.._ ---' ---_-_---- ---`--
_-{-SEWER OR DISPOSAL SYSTEM c' $1.00 I - WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE -- i —.�-- -
OWNER'S PERMIT $ 1 OO ---- - -- — --
�- REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED COX- APPROVALS 1,rE r1NSPEC1OR'SS!GNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING �
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF-- 19' CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(3) I -
ADDRESS FND/OR DRAINFIELD i
14EFEBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL[j DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,.SEWER OR i
PLUMBING AND SEWERS, SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AMM PROPERLY REGISTERED AND/OR --- -_— EM
�- —'�----'-''-----'
DISCONNECT PLUG AN
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF D
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE. ABOVE ABANDON HOUSE SEWER
DESCRIBED RESZDENTIAL PPOPERTY. .. BACKFILL SEPTIC TANKS Q
SIGNATURE ,.. �� - , �i,t"..: ,;� SEEP.PIT S) 0 CESSPOOLS❑
Of PERh1tYT£E js a'"+, t.'...�'`;,✓ 5, ---- - ------------ -
-.._
IOHN A. LAMBIE, COU TY ENGINEER VALIDATION ROBERT A.WOOD, CHIEF PLBG. INSPECTOR
✓,:'CfC, M.
Q. CASH
i t'