HomeMy Public PortalAbout4950 CAMELLIA AVE_Sewer__ C80B6-8OAPPLICATION FOR PERMIT
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A60 COUNTY OF LOS ANGELES SEWER-SEWAG_ E ,DISPOSAL
DEPARTMENT OF COUNTY ENGINEER - - - /"+- q �
BUILDING AND SAFETY DIVISION emLo1NG ,g�� Po ( 9A"iF �/A Av,5
ADDRESS
TORN A. LAMBIE. OOuEngineer
WILLIAM A. JINSEN. Suptp't of Budding LOCALITY C /-LE /
FOR APPLICANT TO FILL IN
'CROSS ST. RK
LEGAL ,�r++ /n� ^ ♦qas
f
DESCRIPTION LOT NO. 4; 7 OWNER d(2, eJ-.".: /1' s/Y//1V.♦S/"� AVE,_
BLOCK TRACT MA IL
`LFL�4,-7 ADDRESS r7 Sz Nd. (!14 .AFLLJA AE
N0.OF SLOGS. /I
SIZE OF LOT (COX G NOW ON LOT CITY 4-M LE CAT TEL. N0. /T (Q/-3 7Z
USE
OF —
BUILDINGS RES 11>97wTl A I- DISTRICT N0. GROUP BK MAP PG I PROCESSED BY
CONTRACTOR
ADDRESS ,.8 CONNECTION
CITY TEL.NOSTATION DEPTH
REGISTRATION N0. ^ STATE .MANHOLE R NCE - UPPER
„A COUNTY E LOWER
NO. 1 DESCRIPT10NO W K FEE -
HOUSE SEWER CONNECTING TO ' axvV
PUBLIC SEWER (w $3.00 TYPE F CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.. CESSPOOL. DRYWELL @ $Z.00
HOUSE SEWER CONNECTING TOP O.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. Nd. OB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT N0. O
WORK TO HOUSE SEWER @ S1.00 U _
ALTER, HOUSE NNT
EW $100 PERMIT NO.
O
., WASTEIAPPROVAL W
CHARGES N
OWNERS PERMIT $ p 00 f CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 4: v REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. _
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE, - INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. -,r� -
SIGNED THIS DAY OF FF_R. I9�Z- NEW HOUSE SEWER � � '
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS 5b N C9M LLI ,y�I SEPTIC TANK,SEEP.PIT(S)
n E
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT Y HAVE RAAD THIS ATO COMPLY
N - - - "-WANDITH
STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESER.REPAIR,
DRYWELL ❑
° WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ° ALTEA,E DISPOSAL
EM
PLUMBING AND SEWERS.
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT
ECTPLUG SYSTEM
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 PROPS Y. - SEEP FPIT(S)P QC CESSP00❑LS ❑
t SIGNATURE
OF PERMITTE
®" / vyLa.Id.0. ROBERT A.-WOOD
E
cK. Id.0. GSH SUPERVISING MECHANICAL ENGINEER
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