HomeMy Public PortalAbout86221 WORTHINGTON DR - Sewer - 1960-07-08 /8A8420 APPLICATION FOR PERMIT
'�°°' e.°' COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILADDRDESSINGlip
JOHN A. LAMBIE. County Engineer
CASSATT D. GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
0
LEGAL OWNER
DESCRIPTION LOT NO
MAIL
BLOCK TRACT ADDRES
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS ._._� B_I$ P6 ,� /yy,.I
CONTRACTOR :1 _J
ADDRESS CONNECTION DATA
7 DEPTH
CITY TEL.NO.` STATION r
J J / sry 7TATE MANHOLE REFERENCE / .t UPPER
REGISTRATION NO l/ G''� / �"`- COUNTY '' �°" '' 4R l
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION,,o' N LENGTH FROM `
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. j M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.. SS
CEPOOL.DRYWELL @ $2.00 P.C.NO.
HOUSE SEWERCONNECTING TO CO.IMP. NO. JOB NO. ..�
PRIVATE DISPOSAL SYSTEM @ $1.00
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
ALTER, REPAIR ORABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPO.AL SYSTEM @ $1.00 PERMIT N0.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 51 Z�-V 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 CONNECT ADDITIONAL
OWNERS AGENT ✓ ` °'"�'"�'✓ BUILDING OR WORK
SEPTIC TANK,SEEP.PITS)
ADDRESS 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 REGULATINGALTER,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 1 AM THE LEGAL OWNER OF THE ABOVE BACKFILL SEPTIC TANKS ❑
DESCRIBED RESIDENTIAL PROPER . SEEP.PIT(S) ❑ CESSPOOLS
SIGNATURE
OF PERMITTE
r ;VALIDATION ROBERT A. WOOD
CK Y O CASH SUPERVISING MECHANICAL ENGINEEFt
s'
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