HomeMy Public PortalAbout8620 WORTHINGTON DR - Sewer - 1960-06-06 E808 oe 8-59 APPLICATION FOR PERMIT 1
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDjNG v
ADDRESS ;.
JOHN A. LAMBIE, CountyEngineerCASSATT D. GRIFFIN, Supof Building LOCALITY ,I z"tt
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL, ,
DESCRIPTION LOT NO. OWNER d
BLOCK TRACT MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICTN0, GROUF MAP PROCESSED BY
BK PG
CONTRACTOR _ J
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ADDRESS CONNECTION DATA
CITY TEL.N0. ,� $ STATION �L' °a# DEPTH f .
R-gTATE MANHOLE REFERENCE 7 f ' UPPER
REGISTRATION N0. ,,,, ❑ COUNTY d - r" LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3,00 1 TYPE OF CONNECTIONr==�. LENGTH FROM•
SEPTIC TANK,SEEPAGE PIT OR Y. CURB I.L. M.L.TO P.L.
PITSAND/ORDRA1NFiELD @ 33.00 -
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.N,C._..e
PRIVATE DISPOSAL.SYSTEM @ $1..00 CO.IMP. N0.
CONNECT ADDITIONAL BLDG,OR I TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEINER @ $1,00 L�
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S . 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE I I- 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 I9_ NEW HOUSE SEWER
OWNER OR l CONNECT ADDITIONAL
OWNERS AGENT-- BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING pLTER,REPALR,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 L AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY, BACKFILL SEPTIC TANKS ❑
SIGNATURE .] e. SEEP,PIT(S) ❑ CESSPOOLS
OF PERMITTEE
7. VALIDATION ROBERT A. WOOD
AL.Q. CASK SUPERVISING MECHANICAL ENGINEER
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