HomeMy Public PortalAbout4817 CAMELLIA AVE_Sewer__ �iM�Wtll�
CEBOB 10.02
7GA042D ' APPLICATION FOR PERMI
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup'1 of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CRDSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
i M MAIL
BLOCK TRACT JII ADDRESS t�
NYG,, OF BBLDG5.
SIZE OF LOT NOW ON LOT r CITY TEL. NO.
USE OF 'n '
BUILDINGS C�.�„ DISTRICT ND. GROUP MAP//�} PROC SSEO BY
CONTRwCTOR �O �`/ �J I /-'G"
ADDRESS CONNNECTION DATA
T
CITY
I.L. NO. STATION�A V DEPTH
TE UPPER
REGISTRATION NO. COl1 NTY MANHOLE REFERENCE LOWER
NO. DESCRIPTION WORK FEE I TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. UR L. M.L.TO P.L. U
PUBLICSEPTIC
SEWER $5.00 ND. /l
SEPTIC TANK.SEEPAGE PIT OR I E� , JOB NO,
PITS AND/OR DRAINFIELD B 510.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM 53.00
CONNECT ADDITIONAL BLOC.OR Q AFFIDAVIT Alv 11110[x1 RECORD.INSTR,NO. DATE
WORK TO HOUSE SEWER Q 53.00
OVERFLOW SEEPAGE PIT,GRAINFIELD
EXTN..CESSPOOL.DRYWELL.MANHOLE55.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM ® S300 STATE ENCROACHMENT
/ PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s zz r 00
AUTHORIZATION TOTAL FEE 7� CONNECTION CHARGE FEE
IHHAVE AT TIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTON TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTORS SIGNATURE
SIGNED THIS DAY OF 19_
OWNER ORI'Y/� NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADOflE55 BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR,SEWER OR
LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT M THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG ANp
RESIDE IN, THE A E SCRIBED ESIOENTIAL PROPE, ABANDON HOUSE SEW ER
SIGNATURE
BACKFILL SEPTIC TANKS ❑
OF PERMITTEE P
'SEEP,PIT(S) ❑ CESSPOOLS 01 1
VALIDATION ROBERT A. WOOD
cK. M.D. CASH SUPERVISING MECHANICAL ENGINEER
FE324 1 0 D 5.00~