HomeMy Public PortalAbout8602 WORTHINGTON DR - Sewer - 1960-06-06 fi80898 8
' 8-89 APPLICATION FOR PERMIT
1
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL +
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS 6
JOHN A. LAMBIE, County Engmoor f;
CASSATT D. GRIFFIN, Supt of Building 1.00ALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL ' p9
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAIL
ADDRES
N0.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF 11-1
BUILDINGS a y DISTRICT NO. GROUPPQ BK MAP PROCESSED BY
CONTRACTOR
s
ADDRESS CONNECTION DATA
CITY -w TEL.NO. . STATION f'> t* - DEPTH j
f� ATE MANHOLE REFERENCE 3`. UPPE
REGISTRATION NO. �" COUNTY ="r� _ O�fEp
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @b $3,00 TYPE OF CONNECTION �` LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR - Y. CURB Ps,L. M.L.TO P.L. -
_
ITS AND/OR DRAINFIELD @ $9.00 __y -
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO CO.IMP. N0. B ' JOB NO..
PRIVATE DISPOSAL SYSTEM @ $1.00 C.
�— CONNECT ADDITIONAL BLDG,OR
WORK TO HOUSE SEWER $1.00
TRUNK PERMIT N0. ROAD HERMIT N0,
@
ALTER, kEPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SE4'!ER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ ..2 00. CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL 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 DAY OF 19_, NEW HOUSE SEWER
OWNER OR ,f CONNECT ADDITIONAL
OWNERS AGENT_ / V s4. . BUILDING OR WORK
ADDRESS. SEPTIC.TANK,SEEP.PIT(5)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ 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 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 RESIDE�AL PRRTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP.PI7(S) C1 CESSPOOLS
OF PERMITTIry.
a
' iLN ROBERTA. woos
CL 111.0e. CASH SUPERVISING MECktAN1CAL
ENGINEER
i