HomeMy Public PortalAbout4918 CAMELLIA AVE_Sewer__ 5 "E-66 APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer am
County of Los Angeles gDDRESG �l.,,l
WM, J. FOX, COUNTY ENGINEER
CASSATT D. GRIFFIN, SaPwT OP 6VILOING LOCALITY /N/E
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL
DESCRIPTION LOT NO. {e T OWNER (�/]) `�,J. /1 �
BLOCK TRA/CT. / YO. MAIL
F � _ ADDRESS(/4/q/17 r/ /1 A��/MI.OX_.Ct6. /�.ArL
SIZE OF LOT,_5'V/_/60_/6O NOW ON B LOTS �J�1 6
CITY ,y�j TEL. NO. " py
USE DI LDINGS
BUII/MSA � DISTRICT N0. GROUP MAP
SPA £si/Wlr
PG
CONTRACTOR GK Z6
ADDRESS q 4?jq �pnn CONNECTION DATA `v
CITY �} 'LC TEL. NO.,-Id-q'- G 3 QQ STATION DEPTH _
/ ❑ STATE MANHOLE REFERENCE
REGIST°ATION NO. ❑ COUNTY UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
ND. DESCRIPTION OF WORK FEE Y. CURB P.L. M,L.TO P.L.
PUROUSE BLIC SEWEgCONNECTING TO @ $ B 50IJD �D TO �neY9 3 S'
HOUSE SEWER CONNECTING TO
_1 PRIVATE DISPOSAL SYSTEM L00
CONNECT ADDITIONAL BLDG. OR CO. IMP. NO. JOB. NO.
_ WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING ��„
SEWER OR DISPOSAL SYSTEM 1.00 _ TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
ANO/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OWNER•$ PERMIT 5 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
TRACTORHAVE TTOS CONNECT ONTRTHEA ABOVECTED WDESCRIBEDITH THE H EXISTING EREIN IDWELLIING ED CON- APPROVALS GATE INSPECTORSSIGNATURE
TO THE PUBLIC SEWER _
SIGNED THIS DAY OF 19—
NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK (_1
Y
ADDRESS SEPTIC TANK, SEEP, PIT(5)
ANO/OR GRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY I
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR, 4.t
1 4 -I ..
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM 10 1' S .t
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
.LICENSED AS REQUIRED BY LOS ANGELES.COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SEEP. PIT(S) Cl CESSPOOLS❑
. SIGNATURE
OF PERMITTEE
WILLIAM J. F , COUNTY ENGINEER VALIDATION
tiBT vACo7 008 4S AUG24 4 2.0 0. In
DEPUTY DEPUTY '-
.BY BT.p//♦
� ® DEPUTY _ • " DEPUTY