HomeMy Public PortalAbout5422 CAMBURY AVE_Sewer__ CES08 D IO-63
BA64 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION - BUILDING '
JOHN A. LAMBIE, County EnginoeI ADDRESS `�
WILLIAM A. JENSEN. Supt of Building /f w
LOCALITY rX�•.y4L/�L9 L".[��(.
NEARESTFOR APPLICANT TO FILL IN `Ross ST. C
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TPA CL' '� gODFE55
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF pIBTRICT NO. GflOUP MAP PROC ED By
BUILDINGS
Yom_ T `,{. J_' BK PG
CONTRACTOR
4 �,�t J%`/�/ y ZED
ADDREss( S t (. CONNECTION DATA .Y
CIT •/ (� a TEL. NO. - �� p STATION D DEPTH
` ) STATE MANHOLE REFERENCE UPPER
REGISTRATION NO, [! ( C• y COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. C RB P.L. M.L.TO P.L.
PUBLIC SEWER @ $3.00
SEPTIC TANK,SEEPAGE PIT OR j//), _ P /C O
PITS AND/..ORAINFIELD SIO,00 C`� B NO. J
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00 1 ^
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT MMY[a [a5[a[NT RECORD,INSTR.NO. DATE F.V
WORK TO HOUSE SEWER $3.00 U
OVERFLOW SEEPAGE PIT.DRAINFIELD W
EXTN.,CESSPOOL,DRYWELL.MANH OLE CD SS.00 d
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING Sn
SEWER OR DISPOSAL SYSTEM 0 S .00 STATE ENCROACHMENT Z
PERMIT NO,
1
INDUSTRIAL
WASTE APPROVAL
OWNERSS PERMIT I 21 00
I I 'dy CONNECTION CHARGE FEE CHARGES
AUTHORIZATION I TOTAL FEE
'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER, APPROVALS DATE INSPECTORS SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK J y
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
SEPTIC TANK.SIELD PIT(S)
ND/ORDRAINFIELD
AND STATE THAT THE ABOVE IE CORRECT AND AGREE E COMPLY
WITH ALL COUNTY RS.ORDINANCES AND STATE LAWS REGUL4TING ❑
PLUMBING AND SEWERS. CESSPOOL ❑ 'ORYWELL
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A�E ES E DENTI Pfl�EgTY.
D ;
4BANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE •I
EEEP.PIT(B) ❑ CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
cK. M.D. CASH SUPERVISING MECHANICAL ENGINEER
LJ1jjo 9 3 9 2 9 1 0 0 5.00-