HomeMy Public PortalAbout5420 ACACIA ST_Sewer_4/26/1962_Road Permit 97448 CESOS 3-61
76AG42D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL.,
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN Al LAM M. County Engineer ADDRESS
WILLIAM A. JENSEN. Sup t of Building_ LOCALITY
NEAREST
FOR APPLICANT TO M IN CROSS ST
LEGAL OWNER !G�► '
DESCRIPTION LOT NO
BLOCK TRACT ' MAIL
ADDRESS
NO F BLDGS �- y
SIZE OF LOT NOW ON LOT CITY �. G, TEL NO v,�' t U
USE OF /
BUILDINGS �(G/�- DISTRICT NO GROUP BK MAP PG PROCESSED BY
CONTRACTOR _ J(t�
ADDRESS "L G� r CONNECTION DATA
va
CITY �r IS, .� TEL NOSTATION DEPTH ,
,.` STATE MANHOLE REFERENCE (l� LOWER
REGISTRATION NO C� UPPER
Zi��i S COUNTY
No I DESCRIPTION OF W15RK FEE v
PUBLIC EWERSEWECONNECTING TO as 00
TYPE OF CON C LENGTH FROM
BE
ANK All DRAENFGELDIT OR S 00 Y C L Y L TO P L
OVERFLOW SEEPAGE PIT DRAINFIELD d
' EXTN CESSPOOL DRYWELL @ S 00 p C NO O
+ HOUSE'SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ S 00 CO IMP NO JOB NO V
CON NECT.ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER S 00
t' 'ALTER"REPAIR OR ABANDON HOUSE STATE ENCROACHMENT 0
SEWER OR DISPOSAL
ISPOSA SYSTEM
@ S 00 PERMIT NO V
INDUSTRIAL a
WASTE APPROVAL N
CHARGES ?
OWNWS PERMT :1 CONNECTION CHARGE FEE
AUTHOR ATION 1 TOTAL FEE I REIMBURSEMENT FEE q
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS ]DATE, INSPECTORS SIGNATUREt
TO THE PUBLIC SEWER. i
SIGNED THIS DAY 0 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT - BUILDING OR WORK I
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION-
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL 11
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQ LOS ANGELES COUNTY A STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR AM THE LEGAL OWNER 0 THE ABOVE BACKFILL SEPTIC TANKS
DESCRIBED RES j _ PROPERTY. SEEP PITS ❑ CESSPOOLS
SIGNATURE '
OF PERMITT i
ALIDATION RO ERT A. WOOD
CK r o cum SUPERVISING MECHANICAL ENGINEER
Uil 1 6 9 6 ,c%,,J' ITR 2 6 1 1 D 2 5.00 �°