HomeMy Public PortalAbout9022 JAYLEE DR_Sewer_3/3/1980_sewer connection 76A642D
CE 908(REV.6,78) "'° APPLICATION FOR PERMIT
�5
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRIC/T•�NO. GROUP MAP PRO SED BY
BUILDING 3 BK 1 ' 'iJ�j�
ADDRESS ,�v/
�� CONNECTION DAT
LOCALITY
NEARESTSTATION DEPTH
•
CROSS ST. Tek-41491
UPPER
MANHOLEREFERENCE LOWER
OWNER TYPE OF CONNECTION LENGTH FROM
MAIL / Y. CURB P.L. M.L.TO P.L.
ADDRESS L
P.C.NO.
CO.IMP.NO. JOB NO.
CITY EL.NO.
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
BLOCK TRACT
AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
c
NO.OF BLDGS. Q
SIZE OF LOT NOW ON LOT ( HWY.OR ST.WIDENING t.
USEOF 1`� STATE ENCROACHMENT
BUILDINGS < PERMIT NO. -
1 INDUSTRIAL
CONTRACTOR ��/ WASTE APPROVAL
ADDRESS Q �i Dr. CHARGES
CITYUP/4jwd TEL. 9 /�L.,y CONNECTION CHARGE FEE
NO.
STATELIC. REIMBURSEMENT FEE
LICENSE NO. ��b I �( CLASS
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE ccu
HOUSE SEWER CONNECTING TO
PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER -,.i
(�
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL l6A
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM
SEPTIC TANK.SEEP,PIT(S)CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER �I AND/OR DRAINFIELD
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL [3DRYWELL❑
EXTN.,CESSPOOL.DRYWELL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE ALTER,REPAIR.SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑
SEEP,PIT(S)❑ CESSPOOLS❑
OWNER'S Permit s C•-(3
AUTHORIZATION TOTAL FEE j p--o VALIDATION
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19- 9 2 Q 2 A
OWNEROR
OWNERS AGENT
ADDRESS .#
IHEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION �'� 1 /� O 0
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY I H:
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ' /,�
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR • O O 1 4L O O U
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF '
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF,AND INTEND TO RE-
SIDE IN.THE ABOVE D SCRI D RESIDENTIAL PROPERTY. 03.03"80
SIGNATURE
OF PERMITT