HomeMy Public PortalAbout8617 WORTHINGTON DR - Sewer - 1960-07-08 GA6
' 8 8
H80008 8.89 APPLICATION FOR PERMIT
7
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRE SG 3
IOHN A. LAMBIE, Count Engineer
CASSATT D. GRIFFIN, Supt of l3uildinq LOCALITY
-- - NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL 6 r
DESCRIPTION LOT NO. J OWNER
BLOCK TRACT MAIL
ADDRES
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAPPROCESSED BY
CONTRACTOR "' _ BK PG
ADDRESS CONNECTION DATA
CITY TEL.N0, ` STATION ," r D` & DEPTH 1
STATE MANHOLE REFERENCE y� d r ! UPPER
REGISTRATION NO. _$' COUNTY . +_,, .fig •� '
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO i
PUBLIC SEWER C-) $3.00 �I TYPE OF CONNECTIO �,, LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L. '+ T
PITS AND/ORDRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIEL.D
EXTN..CESSPOOL.DRYW ELL
@ $2.00
HOUSE SEINER CONNECTING TO P.C.N0. .Rf �.,.✓,_
PRIVATE DISPOSAL SYSTEM @ S1,00 CO.IMP, NO. JOB
CONNECT ADDITIONAL SEWER Cdr $.t.00 IONAL BLDG.OR
WORK TO HOUSE TRUNK PERMIT N0. ROAD PERMIT N0.
ALTER,REPAIR OR ABANDONHOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 OO CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 1 00 CONNECTION
REIMBURSEMENT FEE
? HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE J INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19- NEW HOUSE SEWER _
OWNER OR r'yCONNECT ADDITIONAL
OWNERS AGENT__ ., '` =o'•f� BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(5)
AND/OR RAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL El
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,
DISPOSAL SYSTEM
LTER,REPAIR,SEWER OR
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWADISCONNECT 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. y. BACKFILL SEPTIC TANKS ❑
SIGNATURE ^" SEEP.'PIT(S) ❑ CESSPOOLS
OF PERMITTE Egg
)F VALIDATION ROBERT A. WOOD
/ Ct4 Z.e. CASH SUPERVISING MECHANICAL ENGINEER
6 ' ' t
J-0