HomeMy Public PortalAbout5615 ALESSANDRO AVE_Sewer__ n ;
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®808(REV 6/78) 9 APPLICATION FOR PERMIT , T
SEWER - SEWAGE DISPOSAL
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COUNTY OF LOS ANGELES BUILDING AND SAFETY ,
FOR APPLICANT TO FILL IN DIS`)TRIC/T'Ny�O[j GROUZP Al
CE$SED BY
BUILDING / /
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ADDRESS
CONNECTION DATA
LOCALITY I
NEAREST STATION i DEPTH i z•
CROSS ST I I
UPPER
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OWNER TYPE OF CONNECTION LENGTH FROM
MAIL Y CURB PL M L TO P L
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ADRESS r PC NO 'i 1 µ F
/ r CO IMP NO JOB NO
CITY L NO
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LEGAL TRUNK PERMIT NO ROAD PERMIT NO 1
DESCRIPTION LOT NO
AFFIDAVIT I WAIVER I EASEMENT RECORD INSTR NO DATE
BLOCK TRACT i
�f NO OF BLDGS r
SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
USE OF
BUILDINGS Sr STATE ENCROACHMENT
PERMIT NO
CONTRACTOR INDUSTRIAL
WASTE APPROVAL I
ADDRESSCHARGES
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CITY I NO CONNECTION CHARGE FEE t�
STATE LIC REIMBURSEMENT FEE F
LICENSE NO CLASS 4
NO DESCRIPTION OF WORK FEE r APPROVALS DATE r 1N SPECTOR S SIGNATURE (�
HOUSE SEWER CONNECTING TO
PUBLIC SEWER NEW HOUSE SEWER "� a" 3` >` O
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
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PRIVATE DISPOSAL SYSTEM
CONNECTAODITIONAL--BLDG OR, SEPTICTANK SEEP PIT(S)
WORK TO HOUSE SEWER- I AND/OR DRAINFIELD
OVERFLOW SEEPAGE PIT DRAINFIELD CESSPOOL ❑ DRYWELL❑
EXTN CESSPOOL DRYWELL MANHOLE
ALTER REPAIR OR ABANDON HOUSE ALTER REPAIR SEWER OR
SEWER OR DISPOSALSYSTEMSEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑ - {OWNER'S Permit s SEEP PIT(S)Cl CESSPOOLS❑
AUTHORIZATION TOTAL FEE VALIDATION -
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON r
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ p ;23865A '
OWNER OR
OWNERS AGENT~
OHO O r Ow-
ADDRESS
IHEREBY ACKNOWLEDGE THAT I HAVE'READ THIS APPLICATION ' t r` O O 14.00-
F
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY y
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS I O O O 1 O o1
I HEREBY CERTIFY THA M PROPERLY REGISTERED AND/OR >
LICENSED AS REQUIRED LO ANGELES C NTY AND STATE OF 0 ^—e�^
CALIFORNIA OR THAT 1 A THE L GAL OWNERS AND INTEND TO RE 9 ( 9
SIDE IN THE ABOVE DES RIBE RES ID NR RTY I
SIGNATURE IV
OF PERMITTEE r
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