HomeMy Public PortalAbout5129 CAMELLIA AVE_Sewer__ C EROS 10-63
76A642D APPLICATION FOR PERMI
;7��V4
COUNTY OF LOS ANGEL S$ SEWER—SEWAGE DISPOSAL �1
DIPARTMENT OF COUNTY ENGINEER
BUMDING AND SAFETY DIVISION ■UILOING d_/ Z / C )ELLE vE
b ErintrF. ga //� ADDRESS x r rte, ` o: $� 7 M Pl f C i 7—X
LOCALIT'
'=::".T.
[AR[ST 1- 4 4a r q
FOR APPLICANT TO FILL IN CR°'° f/Ty.� TL/� �[
DESCRIPTION LOT NO. OWN[n/ //�� �r/ip/�CRO//W//` [] //,'rw�•v/�`_
BLOCK / (�TR�A[CTJ 7/Q�6$ � I� Ab DR[ef L/ 17 q /SCA/4 et 1
Slu OF LOT��1 J� ( /� / NONo.W°ON LLOTOT■. Lr CITY'TEMP�6 6,7, NO. `O (J fi7
USE OF M DISTRICT NO. GnOUP MAP BY
BUILDINGS O• 041f A-
T BK PG
CONTRACTOR o �.[/ E0 ..fes
ADDRESS CONNECTION DATA
STATION t DEPTH
CITY TEL. NO.
STATE MANHOLE REFERENCEUF'KR
REGISTRATION NO. B COUNTY
No. DESCRIPTION OF WORK FEE TYPE OF CONNECTIONLENGTHFR011f
HOUSE SEWER CONNECTING TO CURE P.L_ M.L.T(u.
PUBLIC SEWER i .00 P.C.NO.
■ PTIC TANK,SEEPAGE PIT OR CO.IMF.NO. JOB NO.
FITS ANP/OR DRAINFIKLD XIO.00
HOUSE SEWER CONNECTIF40 TO TRUNK PERMIT NO. ROAD PERMIT NO. CC
PRIVATE DISPOSAL SYSTEM $3.00
COMNKCt ADDITIO L BLDG.O _� AFFIDAVIT SAME LASES!LfT RECORD.INS:F NO. DATE
WORK TO HOUSE S[W[R S3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
E)CTN.,CESSPOOL,DRYWELL,MANHOLE $5.00 h
AL R, ORA DO HWY.OR Wr.WIDENING
SEWER OR DISPOiAL SY/TEM X7.00 STATE XNCROACHMLMT
PERMIT NO.
INDUSTRIAL
���T�pia WAIT[APP RO V A L
O[VNEI: S PERMIT $ 2 00 CHARGES
AUTHOEIY.ATION TOTAL FEF CON N[CTIOn CHARD[F[[
'I HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMED CON- R[IN■URSXM[NT FII
TRACTOR TO CONNECT THE ABOVE D[SCRIBm Tp
TO TH[ PUBLIC SEW //� APP�OVAJ.�7 DAT[ INSPECT IPS SIONATURE
SIGNED THIS DAY
OWNER OR NEW HOUSE■EWER
OWNERS AGENT Lic 4 CONNECT ADDITIONAL
/ BUILDING OR WORK
ADDRESS SEPTIC TANK.ON".PIT(a)
I HERESY KNOWLEDO[ THAT 1 HAVE READ THIS APPLICATION AND/OR DRAI NPI[LD
AND STAT[ HAT THE ANOVA IS CORRECT AND AGR[[ TO COMPLY
WITH ALL COUNTY 0RDINANCC/ AND STAT[ LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ElDRYW[LL El
IHERESY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,IR AIR,SEWER OR
LICENSED AS REQUIRED ■Y LO■ ANGLES COUNTY AND STATE OF ■[WAG[DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND I ND TO DISCONNECT PLUG AND
RESIDE
IN, T�VlEDL@CFtIRI1D RABANDON NOUS[SEWER
SIGNATUREl/7 SAC KFILL f[F[J_C TANKS ❑
OF PERM I SEEP,PIT(S) LJ C_X"POOIJEl
ALM.0. N SUPERVISING ROBERT O
NG MCHANICAAL
M. ENGINEER
ti CK. O. CASH
co
LAC,01 3 9 0S rR19 1 0 0 5.00N