HomeMy Public PortalAbout5215 CAMELLIA AVE_Sewer__ r -
7eAr��d — cEeoe — 9/7e APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
D�ARTMENT OF COUNTY ENGINEER
DUJLDING AND SAFETY DIVISION BUILDING
AD-DRE" ` y /-
LOCALrrY I
NEAREST
FOR APPLICANT TO FILL IN �« ST.
LKdAL
DESCIRIFTION LOT NO. OWNER
MAIL
BLOCK TRACT / ADORED
OF NLOS.
SIZI OF LOT / NOW OR LOT CITY TEL. NO.
USE Of
DISTRJCT RO. SROUP MAF FR [Be[D By
BUILDINGS
8 PB
V_ R .v - —
STATION DtrTH
NO.
STATE LIG /� MANHOLE REFKJMKCS UPPER
LIC[NS[ N OLAM 6,r LOWER
No. DKSCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWR CONNECTING TO Y. CURE P.i M.L TO P.L
PUBuc SE'WbR • $7.00
SEPTIC A FIT OR F.C.NO.
PITS AMD/OR DMINFI[LD � 510.00
CO.IMF.NO. JOB MO.
HOUSESEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $7.00
CONNECT ADDITIOfV1).BLDG.OR AFFIDAVIT I SAlrif I fYLWM RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER [7-00
OVERFLOW S[KPACkK PIT.DRAINFIELD S
E(TN_CESSPOOL.DRYWKLL $$.00
H WY.OR R.WIDEIING QoC
SEW.OR SYSTEM P2.00 STATE ENCROACHMENT W
MAIRHOL[ $7.00 PERMIT NO. L�L2
INDUSTRIAL
�����}�+pp�� WASTE APPROVAL =
�}�O T11Nr-.�8H} �r s 00, CHARG[a
AU 1i30i7M710N rnAL FEE CONNECTION CHARq[FI[
I HAVE AT THIS DAT[ A CON'TR.ACT WITH THE HEREIN AMED COM- 11EIMBURSEMENT FEE
TRACTOR TO CONNECT THE AB [OVDESCRIBED EEIBTI1/0 EL
LIDWLING
�p S-�
TO TH[ FUBC SEWER. APPBOVA S DAT= INSPECTOR'S SIGNATURE
SIGNED THIS DAY OR
OWN"OR NEW HOUR SEWER
OWNERS AGENT COTIN[GT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS AANb/O
-APPLICATION TANK.R@.PIT(S)
AND STAT[ THAT THE AeQVE IS CORRECT AND AGREE TO COMPLY Nb/OR DRAINFI[LD
WITH ALL COUNTY ORDINAN CKS AND STATE LAWS REOULATING CE/.BPOOL ❑ DRYW[LL ❑
LCK
G AND SEWERS.
BY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR AIR.SEW[]1 OR
AS REQUIRED BY LOG ANGLES COUNTY AMD STATE OF O[DISPOSAL tYST[M
IA OR THAT I THE LEGA [NKR OF. AN INTEND TODISCONHKCT PLUG AND
N. tHE ABO RIBED DENT7 PRABANDON HOUSE SEWER
RE BACKFILL SEPT TANKSMITTEI REP.PIT(S) U CESSPOOLS
VAI.IbATION <ME,- M.0. CASH
COMPENSATION
4. 6 MAY 1.2 1 %D 1) 1 4.0 0
POLICY HOLDER:
POLICY NUMBER: f3-L .3