HomeMy Public PortalAbout5435 CAMBURY AVE_Sewer__ )eAe4Yo 4
CE 808 leEv.enel APPLICATION FOR PERMIT .
@/s ,
_ SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY/
FOR APPLICANT TO FILL IN DISTRICT NOY I GROUP' . • :MAP ESSED BY
c`�-- BY PG
BUILDING 1 J /,� _ /®
ADDRESS .J ✓ r'L✓E(.GJ_ VVV 'j--
r� / CONNECTION DATA
LOCALITY C C,' - ✓ ,
NEAREST 1 I /�J STATION • DEPTH
CROSSST. (/
UPPER
MANHOLE REFERENCE _ LOWER
OWNER `•u H �i P s/ U •/ ) D I
TYPE OF CONNECTION ' LENGTH FROM -
MAIL K CURB P.L. No.TO P.L.
ADDRESS P.C.
ADD ,
r
CITY ' TEL NQ J — ` •• CO,IMP.NO. OB NO.
LEGAL ` TRUNKPERMITNO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFi1DAVIT WAWER EASEMENT RECORD.INSTfl.NO. GATE
BLOCK TRACT
NO.OF CLOGS..
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERM?NO.
INDUSTRIAL
CONTRACTOR WASTE APPROVAL
ADDRESS
CHARGES
CRY , TEL.NO. CONNECTION CHARGE FEE
STATE LIC. REIMBURSEMENT FEE
LICENSE NO. CLASS O
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE V
HOUSE SEWER CONNECTING TO Qf
PUBLIC SEWER O
NEW MOUSE SEWER
SEPTIC TANK.SEE RAINFIEPILOR. .- — -
PITS HOUS NS/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK Q �?
PRIVATE DISPOSAL SYSTEM
BE CONNECT A •�C'.OR AND/O DRAIN EEL,PRI51
WORK TO HOUSE SEWER- - -_ - AND/OR DRAINFIELD
OVERFLOW SEEPAGE PR.GRAINFIELD CESSPOOL ❑ DRYWELL❑
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
_ BAC KFILL SEPTIC TANKS
OWNER'S _
Permit 5 SEEP 5) CESSPOOLS 01
AUTHORIZATION TOTAL FEE ' VALIDATION
.[,HAVE.AT THIS DATE,A CONTRACT.WITH THE HEREIN NAl ED CON- .._ y 67
q p �L _
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING C LA•/r/2 5 A
TOTHE PUBLIC SEWER.
SIGNED THIS' DAY OF - • 19_ - # 0 0 0 e 1 Q`
OWNEROR '
OWNIEflS AGENT •. . . .. 4
O"O j .00
.- •.
ADDRESS �
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION .Q. -14,005
AND STATE THAT THE A80VE IS CORRECT AND AGREE TO COMPLY '
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. - _ -� 09. 1-7-79
-7'9 -
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF.AND INTEND TO RE-
SIOE IN,THE ABOVE DESCRIBED RESIDENTIAL PR/OPER�TY.
SIGNATURE - //_ .h� ��l - -
OFPERMITTEE �'A>7��y