HomeMy Public PortalAbout4912 CAMELLIA AVE_Sewer__ DERDB 3-84 APPLICATI N FOR PE MIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE. County Engineer ADOREss / , A
WILLIAM A. JENSEN, Supt of Bufldf09 LOCALITY
IC,GJ u
NEAREST C
FOR APPLICANT TO FML IN CROSS 6T.
LEGAL $
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRES6
(`�O. OF BLOCS.
SIZE OF LOT'/ (C V ryOW ON LOT CITY TEL. NO. IF
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
_ BH PG
CONTRgCTOfl
ADOR s �'� ,y,:.c. .�1, CONNECTION DATA
Y STATION DEPTH
CTL ) J T 4 Lc1E No.
S
UPPER
REGISTRATION NO CTUNTY N
LOWER
NO. 1 DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER S5.00
BEPTIC TANK.SEEPq GE PIT OR CO.IMP. NO. JOB NO. d
PITB AND/..GRAINFIELD SIO.00 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. U
PRI TE OI SPOSAL SYSTEM S3.00
ONNECT ADDITIONAL BLDG.OR AFFIDAVIT WHY[• 45[v[xi RECORD.INSTR.NO. DATE m
WORK TO HOUSE SEWER $3.00 wO
OVERFLOW SEEPAGE PIT.ORAINFIELO b
EX N..CESSPOOL.DRYWELL.MANHOLE $5.00 ly
HWY.OR ST.WIDENING
_ ALTE REPAIR OR ABANDON HOUSE 11
OR DISPOSAL SYSTEM ® E3.00 06; STATE ENCROACHMENT h
PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT sl z 00
AUTHORIZATION TOTAL FEE '%1 . 06
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 5EW 1 APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS_ DAY OF_
AeO6_ [962
OWNER ORA NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING ORRWORK WORK
ADDRES6 L/ V
SEPTIC TANK.SEEP.PIT(5)
1 HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION AND/OR GRAINFIELD
AND STATE THAT THE ABOVE ICORRECT AND AGREE COMPLY
WITH ALL COUNTY ORDINANCES
S ANO STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYW ELL ❑
I HEREBY CEPTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR,6 EWER OR /
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAG E"SPS
SYBTEM
CALIFORNIA OR THAT M THE LEGAL OWNER AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABO E ESCRIBEO RE DEN ROP TV. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE_ _ SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT WOOD
SUPERVISING MECHANICAL ENGINEER
CH, M.0. GSH
Ll1�o0 5 4 9'� SEP 11 t o n 5.00-