HomeMy Public PortalAbout4925 CAMELLIA AVE_Sewer__ 988.�69��3 APPLICATION FOR PERMIT MIT
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deparnnent of County Engineer -
County of Los Angeles BUILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS �' P
CASSATT 0.GRIFFIN, SUPT of BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL 1/1 3
DESCRIPTION LOT NO. OWNERMAIL 6
BLOCK ''')(TRACT �j ADDRESS % G�/•- I
SIZE OF LOTSM/ O NOW
OF
LOTS -CITY TEL. NO.
USE OF -- '
BUILDINGS DISTRICT NO. GROUP MAP
CONTRACTOR - v I PG
ADDRESS P n CONNECTION DATA
CITY TEL. NO. �^ V /' STATION DEPTH
❑ STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. ❑ COUNTY LOWER
11i6NkL
NO. DESCRIPTION OF WORK FEE 7d 9 7 �- 84'7
TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER NOOSE SEWER CONNECTING TO Y. CURB F.L. ,M.L. TO P.L.
Q S 3.5D
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM LOO _
CONNECT ADDITIONAL BLDG. OR
V WORK TO HOUSE SEWER 1.00 O 0 CO. IMP. N0. JOB NO.
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
OWNER'S
PERMIT 1 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE O REIMBURSEMENT FEE
I HAVE, DATECON-
TRACTORTTOS CONNE TO THE ABOVE DESCRIBED EXISTINWITH THE HEREIN1GpMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS_—DAY OF 19 NEW HOUSE SEWER
OWNER OR . CONNECT ADDITIONAL
OWNERS AGENT BUILDING WORK
SEPTIC TANK.SEEP. PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL O
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR. SEWER OR
PLUMBING AND SEWERS. SEWAGE REPAIR.
DISPOSSEWER EM
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 I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑.
n SEEP. PIT(5) ❑ CESSPOOLS El C.:
OF PERMITTEE
WILLIAM J.FOX,COUNTY ENGINEER VALIDATION R.A.WOOD, CHIEF PLSG. INSPECTOR
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