Loading...
HomeMy Public PortalAbout5239 BARELA AVE_Sewer__ CE808A,4/72` APPLICATION FOR PERMIT 76At`i42L COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING �q ADDRESS O'er /j� ) LOCALITY TE O f C 17 NEAREST FOR APPLICANT TO FILL IN CR05S ST. DESLEAL CRIPTION LOT NO. OWNER MAIL BLOCK TRACT ADDRESS O SIZE OF LOT NOW ON LOTS CITY TEL. NO, g USE OF D�ISTR41CTGROUP MAP PRO ESSED BY BUILDINGS y/�� BK PG CONTRACTOR N 6 l ADDRESS® S /V,J`-' CONNECTION DATA STATION DEPTH CITY TEL. NO. S-��v STATE LIC M HOLE REFERENCE UPPER LICENSE NO._ AC)a GLASS LOWER NO. 1 DESCRIPTION OF WORK FEE YPE OF CONNECTION LENGTH FROM HOUSE SEWER CONNECTING TO Y. CURB P. M.L.TO P.L. PUBLIC SEWER @ P.C.NO. SEPTIC TANK.SEEPAGE PIT OR CO.IMP.NO. JOB NO. PITS AND/OR DRAINFIELD @ O HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. U PRIVATE DISPOSAL SYSTEM CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT R ORD.INSTR.NO. DATE WORK TO HOUSE SEWER O OVERFLOW SEEPAGE PIT.DRAINFIELD V EXT N..0 ESSPOOL.DRYWELL,MANHOLE @ W Wi26fY!REPAIR HWY.OR ST.WIDENING p, SEWER @ STATE ENCROACHMENT PERMIT NO. INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT S �� AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEW R. APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF 19n OWNER OR ` NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL ADDRESS 1 BUILDING OR WORK SEPTIC TANK,SEEP,PIT(S) I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL DRYWELL ❑ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.J E �4 PASEWER OR -'l /. .JT. LICENSED AS REQUIRED BY LOS A G ES COUNTY AND STAT OF SEWAGE-DISPOSAL SYSTEM �� ✓1 - -- CALIFORNIA OR THAT I A THE LE AL WNER OF, AN INT D TO DISCONNECT PLUG AND RESIDE IN, THE ABOVE SCRIBE RE SI ENTIAL PRO/"R ABANDON HOUSE SEWER SIGNATURE y BACKFILL SEPTIC TANKS ❑ OF PERMITTEE SEEP.PIT(S) ❑ CESSPOOLS ❑ VALIDATION CK. M.0. CASH 5 3 Olt--OGT 14 I©D 91,0 0 B