HomeMy Public PortalAbout5718 CAMELLIA AVE_Sewer__ "°° APPLICATION FOR PERMIT
7u�41D COUNTY OF LOS ANCRU, SEWER—SEWAGE DISPOSAL -
DEPARTWM OF COUNTY ENS
WaXIING AND SAFETY Ein-MON BUILDING
ADDRE.0
LOCA LI TT
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FOR APPLICANT TO FILL IN 'CROs,
LEGAL 1 0*XHR
DESCRIPTION LOT N0.
BLOCK TRACT 4
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SIZE OF LOT d A NOW ON LOT
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REGISTRATION N0. COUNTY MANHOLE REFIZIt"CR �' P
No, uuD EE ��}}Ryy P�� R FEE
PUBLICSJA%E ONXECTIX TO 5.00
SEPTIC T/lXK SEEPAGE PIT OR T. �E CUQB on
NP LENGTH TO��
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PWER CO .C.NO.
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7D�HOU,E 3E�►ERBLOG.OR TRUNK PMXIT NO. ROAD PiR1IT NO. g
R, E A OR ABANDON HOUSE STATE EACROACHREXT
PERMIT NO.
IXDUS141AL
ADTE APPRO
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OMfEWS PElWT p OO CONNECTION CHARD¢FU
AUMORMTION FTOTAL FEE a IM1119URSE4QAT 1*EE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVI DESCRIBED STING DWSLLIPIG APPROVALS OATI IIaP R'S PIGPLATUIZX
TO THE PUBLIC SEVER
SIGNED TH18 DLY O 119_ NEW HOUSE SEWER
OWNER Olt CCONNECT ADDITIONAL
OWNERSAGE 46',D�,- BUILDING OR WORK
SEPTIC TANK,Stu.FIT(a
L ADDRpsa AJI OR DRAINFFEID -
If 1 HER®T. ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATS THAT THE ABOVE IP CORRECT AND AGREE TO COMPLT CESSPOOL D
WITH ALL COUKTT ORDINANC AAD STATE LAWS REGULATING
PLUMBING AAD SEW¢lJ. ALTER.REPAIR,SEWER OR -
I XT CERTIFT THAT II Al P'ROMITO REGIVIMM AND/OR bEI/AGE DISPOSAL STDT®
CLICAGI �OR OTHAT�1 BAl THE LEGAL OWINH,R �D STATE OF DISCONNECT PLUG AND
OF THE ABOVE ADAXDON HOUSE SEM EH
RX ADESCRIBED RESIDEIAL PROPERTY. BAC"IL{ SEFTJCTAXKS
SIGNATURE SEEP.PIT 3 CESSPOOLS ^r
OF PFREITTIW. —
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