HomeMy Public PortalAbout8616 WORTHINGTON DR - Sewer - 1960-06-06 808 8 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDIjgG AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE, Counter Engineer 42
CASSATT D. GRIFFIN, Supt of Building LOCALITY ' . l-e € .
r WONNEAREST . .
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL r3 �
DESCRIPTION LOT N0. __OWNER��
BLOCK TRACT Jg MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL, NO.
USE OF
BUILDINGS t �--' ----rs- {--£- `— DISTRICT NO. GROUP I MAP PROCESSED BY
BK PG
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL.NO. _ �r STATION ,i jr < DEPTH
.t ry (��STATE MANHOLE REFERENCE r tfPPER
REGISTRATION NO. / /e° ' :eY�� ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO -
PUBLIC SEWER to $3.00 fw TYPE OF CONNECTION :: LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB .P.L.. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD '-
EXTN.,CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO. / .-
PRIVATE DISPOSAL SYSTEM C $1.00 CO.IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER $1.00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM C� $i.OQ PERMIT NO.
INDUSTRIAL
�I WASTE APPROVAL
CHARGES
OWNER'S PERMIT 21,00 CONNECTION CHARGE FEE
AUTHORIZATION 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 OF 19, NEW HOUSE SEWER
OWNER OR k,- CONNECT ADDITIONAL
OWNERS AGENT- ( --" �� BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
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 RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE �/ `' SEEP.PIS) E) CESSPOOLS
T
OF PERMITTE c r
)y "VALIDATION ROBERT A. WOOD
U.0. CASH SUPERVISING MECHANICAL,ENGINEBR