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HomeMy Public PortalAbout9462 WORKMAN AVE_Sewer__ 24650 (NSEATS »AG42® APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER--SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION A�aae�sG 66 IOH A. LAMBIE, County Engineer WILLIAM A. JENSEN, Supt of Building LOCALITY ^" NEAREST FOR APPLICANT TO FILL IN cxoss ST. �l LEGAL DESCRIPTION LCT NO. ".`� OWNER BLOCK TRACT + MAIL ADDRESS . NO,OF SLOGS. SIZE OF LOT `- NOW ON LOT CITY TEL. NO. USE OFDI DISTRICT NO. GROUP MAP PROCESSF�OBY BUiLBUILDINGS _ ] BK PG CONTRACTOR j �d "� >� ADDR -~'" �, ,u, CONNEC ION .DATA _ CITY TEL.N0.-� r a / -s f5 FJ DEPTH 9 ,,,t� � , STATE ANHOLE REFERENCE ".� e REGISTRATION NO. COUNTY COUNTY NO.^ DESe?IP'T;()1 OF WORK FEE HOUSE SEWER CONNECTING TO PUBLIC SEWER @ $3.03 9' f TYPE OF CONNECTION LENGTH FROM SEPTIC TANK,SEEPAGE PIT OR Y. CURS P.L. M.L.TO P.L. PITS AND/ORDRAINFIELD @ $3.00 OVERFLOW SEEPAGE PIT, DRAINFIELD ( -�,� ,t .,� EXTN, CESSPOOL.DRYWELL. @ $2.00 P C.. HOUSE SEWER CONNECTING TO �, Cr N0. CO.IMP, N0. PRIVATE DISPOSAL SYSTEM. @ 81.00 _ JOB N0, a CONNECT ADDITIONAL BLDG.OR. TRUNK PERMIT NO. ROAD PERMIT N0. <=�<° ` � 0 WORK TO HOUSE SEWER SI.00 ALTER:REPAIR OR ABANDON HOUSE S 'M-E1QT SEWER OR UiSPOSAI.SYSTEM 'v $1.00 I S _ ��," ) ; E� 'ffUT9-A�RA9=VA L OWNER'S PERMIT g 2 00 CONNECTION CHAk,i F lk � AUTHORIZATION TOTAL FEE `REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBEDEXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE TO 'THE PUBLIC SEWER. - SIGNED THIS DAY OF 19— NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENT - ' _ BUILDING OR WORK ADDRESS. _ SEPTIC TANK,SEEP.PIT($) --- AND/OR DRAINFIELD IH ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE 'TO COMPLY CESSPOOL E DRYWELL 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 -.ISCONNECT PLUG AND LICENSED AS REQINRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA. OR THA A I M THE .LEGAL OWNER OF THE ABOVE -- DESCRIBED RESIDEN AL JAROPERTY. BACKFILL SEPTIC TANKS SIGNATURE / S'.EP' PIT,S) LJ ,ESSPOO S< 11 OF PERMITTEE .A. --- —,i,i i �7F VALIDA'TIO ROBERT A. WOOD CK. x.a. CASH SUPERVISING MECHANICAL„ENGINEER 24650 INSERTS'' APPLICATION p /'� ©gyp r` 76AGi D APPLICATION FOR PERMIT' �snsazo COUNTY OF LOS ANGELES SEWER-SEWAGE DISPtJSAI. DEPARTMENT OF COUNTY ENGINEERS BUILDING AND SAFETY DIVISION BUILDING ' IOIiIv A. LAMBIE, County Engfneor WILLIAM A. JENSSEN, Supt of Building LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST. LEGAL f r DESCRIPTION LOT N0. k: ,. - '',d OWNER BLOCK TRACT MAIL ADDRESS N OF BLDGS. SIZE OF LOT NSIW ON LOT CITY TEL. NO.. USE —BUILDINGS BK P�DISTRICT NO. GROUP MAP PROCESSEp BY CONTRACTOR r ADDRESSY y CONNECTION DATA V CITY TEL.NO. ' A TIOP}` ',, DEPTH �. STATE MANHOLE REFERENCE REGISTRATION NO. L� COUNTY fj; DESGRIP7f NOF 1 ORK EE OLSE S 4Yc:R CONNECTING TO BLIC_SEWER C� $5,00 TYPE OF CONNECTION LENGTH FROM -_ SEPTIC TANK,SEEPAGE PIT OR Y CURB P L. M.L. TO P.L. _ PITS AND/OR DRAINFIELD C�? $3.00 OVERFLOW SEEPAGE PIT.DRAINFIELD r FXTN CESSPOOL, DRYWEi L @ $2.00 l ,x A" HOUSE SEWER CONNECTING TO , P C.NO. mak' PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP, N0. 'y Yl�:=, JOB NO. CONNECT ADDITIONAL BLDG.OR " WORK TO HOUSE SEWER @ $1__00 TRUNK PERMIT NO. ROAD PERMIT NO>', ALTER.REPAIR OR ABANDON HOUSE STATE ENCROACHMENT SEWER OP..DISPOSAL SYSTEM @..$1.00 PERMIT NO. O INDUSTRIAL L.9 WASTE APPROVAL - 94 CHARGES 0R'5 I PERMIT CONNECTION CHARGE FEE AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE I 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 DAY OE 19-T NEW HOUSE SEWER OWNER ORCONNECT ADDITIONAL i OWNERS AGENT BUILDING OR WORK 1 ADDRESS. SEPTIC TANK,SEEP.PITS) -- -- ANO/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAM I HAVE READ 'THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL CI DRYWELL [I WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR PLUMBING AND SEWERS' _SEWAGE DISPOSAL SYSTEM 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRE BY..LOS ANGFLES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT i TI4E LEGAL OWNER OF THE ABOVE - DESCRI13ED RESIDENT' L P OPERTY. BACKFILL SEPTIC TANKS ❑ - '` SEEP.F1T(S) ❑ CESSPOOLS Q SIGNATURE rye J__ OF PERMITTEE � �F VALIDATION ROBERT A. WdOD CK. M.o. d' CASH SUPT R1CiSIhiC IvIECI AtdICAL ENGINEER S�! 9