HomeMy Public PortalAbout9632 WOOLLEY ST_Sewer__ 7SA642D
S&E-603 11.55 APPLICATION FOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE -DISPOSAL
Department of County Engineer
County of Los Angeles I'.RE.'
ll L111G
JOHN A. LAMBIE. COUNTY ENGINEER
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
j T-V
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
OWNER
DESCA
_LP LqT NO OWL__L
MAIL
BLOCK TRACT -ADDRESS
NO. 0 BLDG
SiZE_OF LOT jq t CC It TYTEL. NO, T.
---nw ONLOT
USE OF
BUILD NGS Ai DISTRICT No . GROUP MAP
G�_ BK PG
CONTRACTOR
CONNECTION DATA
ADDRESS
STATION DEPTH
CITY
TEL. NO.
'
MANHOLE REFERENCE
TATE LOWER
REGISTRATION NO. COUNTY
NO. j H'k-RIPTION OFWORKFEE
HOUSE SEWER CONNECTING TO
TYPE OF CONNECTIOD. LENGTH FROM
CURB P.L M.L.TO P.L.
2UB CSEWER @ $"..50, Y-
SEPTIC TANK,SEEPAGE PIT OR
—PITS AND/OR DRAINFIELD $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD C. NO. i
EXTNCESSPOOL,DRYWELL,MANHOLE 2100
—HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Gk $1.0 0 TRUNK PERMIT NO, ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR
STATE ENCROACHMENT
WORK TO HOUSE SEWER_ I $1'0o— PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q0 $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT 1 00
AUTHORIZATION 1--TOTAL FEEREIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HMIN NAMED CON. APPROVALSDATE 1 NSPECTC,-R;S SI GNAT URE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISIING DWELLING
TO THE PUBLIC SEWER, NEW HOUSE SEWER
SIGNED THISDAY OF CONNECT ADDITIONAL
OWNER OR a —BUILDING-OR WORK
OWNERS AGENT— SEPTIC TANK,SEEP,PIT(S)
—ADDRESS AND/OR DRAINFiEL-D---—
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOLIO DRYWELLCj
AND SrATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
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 THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PRQ?1ERTY, BACKFILL SEPTI.,
'C TI,NKS 0
SEEP.PIT(S) Cj CESSPOOLS
SIGNATURE
OF PERMITTEE x
10HN A. LAMBIE. COUKTY ENGINEER VALIDATION ROBERT A.WOOD,CHIEF PLBG. INSPECTOR
CK. M. 0. CASH
4 7