HomeMy Public PortalAbout5724 CAMELLIA AVE_Sewer__ D
S&E-669 11.85 APPLICATION FOR PERMIT 1
S&E•8
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN, SUPT OF BUILDING
LOCALITY t'
NEAREST
! TO FILL ceoss sr.
FOR APPLICAN
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It
DESCRIPTION LOT NO.-15,
O LEGALr OWNER ,._
MAIL
BLOCK TRACT �� ADDRESS .. ',•...-j• � - ___
NO. OF BLDGS. CITY TEL. NO.
SIZE OF LOT - NOW ON LOT
USE OF
BUILDINGS DISTRI�O. GRO UP #.KMAP PG
CONTRAC
ADDRESS % CONNECTION DATA F
—7� STATION DEPTH _
N0. /" ,+! I
MANHOLE REFERENCE `f UPPER
y El STATE ` �i LOWER
REGISTRATION NO. •`y', �� yI ❑ COUNTY
No. DESCRIPTION OF WORK FEE
TH FROM t
HOUSE SEWER CONNECTING TO � Jt
Y TYPE OF CU B TION P.L. MELLTO P. L. 3�
PUBLIC SEWER @ $3.50 U
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00 //��
OVERFLOW SEEPAGE PIT,DRAINFIELD CO. IMP. NO. V� P. C.N O
_EXTN.,CESSPOOL,DRYWELL,M AN HOLE @ $ 2.00 ,
HOUSE SEWER CONNECTING TO Q
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG,OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT 1 00
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. r i„ NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR y' BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS �� AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTE D A D/OR
LICENSED AS REQUIRED BY LOS ANGELES NTY D DISCONNECT PLUG AND COUA ST E
F OABANDON HOUSE SEWER
CALIFORNIA OR THAT I- AM THE LEGAL' OWNER 0 THE ABOVE
DESCRIBED RESID'�NTIAL PROPERTY. BACKFILL SEPTIC TANKS El
SIGNATURE -� SEEP.PITS) ❑ CESSPOOLS rid.' °-�''�i 'Ai
OF PERMITTEE—
JOHN
ERMITTEE �`�
JOHN A. LAMBIE, COUNTY ENGINEER ,VALIDATIC ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. CASH
v 1 a 2 8- OCT3,) 4 .5 0 in
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