HomeMy Public PortalAbout4935 CAMELLIA AVE_Sewer__ °a '° 82 APPLICATION FOR PERMIT
TS 'azo .. _.
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL _.
'DEPARTMENT OF COUNTY ENGINEER
_
BUILDING AND SAFETY DIVISION _ BD ILDINO
JOHN A. LAMBIE, County Engineer ADDftess �� /,j:S
WILLIAM A. JENSEN. Supt of Building
LOCALITY'
NEAREST
FOR APPLICANT TO FILL IN CROSS ST,
LEGAL c I �:Yv L / /
DESCRIPTION LOT NO. OWNER
i
.....-.. . .._. ._. r. ... _ MAIL
BLOCK TRACT ADDRESS
-- - - NO:OFBLESS-, -
SRtC OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS - 'DISTRICT NO, GROUP MAP PROCESSED BY
/ r n !�/' /I B PG
CONTRALTO , .GC+L. L�S^L,e- LS J ♦// Imo/ - ()PR
ADDREss - ^{� CONNECTION DATA. . ..
CIL TEL. N _ !� '3119 STATIONDEPTH
STATE UPPER
M
REGISTRATION NO. ^f/, /
FIA ROLE
REFERENC
/ 4"/ Y ❑ COUNTY LOWER
NO. ,.DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH EROM
HOUS H SEWER CONNECTING TO Y. CVRB P.L. T°P.L. V
PUBLIC SEWER 55.00 P.0.NO, B,.
SEPTIC TANK,SEEPAGE PIT OR CO. IMP. NO JOB NO.
PITS AND/OR
GRAINFIELD @ 510.00
HO U SE SEWER CONNECTING TO T K N O D ERMIT NO.
PRIVATE O IBPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR pFFI°A T nl RECORD.INSTR. NO, DATE
WORK TO HOUSE SEWER Q 53,00
OVERFLOW SEEPAGE PIT,GRAINFIELD
E%TN,.CESSPOOL,DRYWELL,MANHOLE @ $5.00
R[T[R,REPAIR OGABAHGON HOUSE HWY.O.ST.WIDENING
SEWER "M 5300 0/9
STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ z 00
AUTHORIZATION TOTAL FEE f �J '00 CDNNECTID RGE 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 SEWER.- APPROVALS DATE INSPECTOR'$SIGNATURE
SIGNED THIS DAY OF I9_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECTA°OITIONAL
ADDRESS BUILDING OR WORK
SEPTIC
/O
G
.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ATANK,sEER PITIS)
�OR DRAINFIELO
'AND STATE THAT THE ABOVE IS CORRECT'A AGREE COMPLY
WITH ALL COUNTY ORDANDSTATE AND STATEE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND1OR ALTER,REPAIR.SEWER OR
LICENSED AS RE°UIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEIf
M
CALIFORNIA OR THAT IM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOV DESCH ED RESIDENTIAL ROEERTY. ABANDON HOUSE SEWER
SIGNATURE (P
OF PERMITTEE - - BACKFILLSEPTIC TANKS ❑
SEEP.PITIS) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
CKSUPERVISING MECHANICAL ENGINEER
. M.O, Cps - `
LACO1 8-8r2 AM22 1 o_a 5.00- a