HomeMy Public PortalAbout5743 CAMELLIA AVE_Sewer__ c
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APPLICATION FOR PER IT
OF LOS ANGE= SEWER-SEWAGE DIS SAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FA
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]]OH21 A IMCBM Co>m Eo ffx U• dWELLLILM JL IENSM, Sup'@ of D>�q LITYGmoommmoompom ESTFOR APPLICANT TO FILL IN * ST. �*
! DESCRIPTION LOT NO. OW N[R l�iy .7
MAIL
BLOCK TRACT APDR[SS
NO. OF ■LDOS,
SIZE OF LOT NOW ON LOT CfTY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROC[ SY
■U IL-DINGSS.
■K PO
CONTRACTOR ?f (,1 in -5A
C.J(G S
ADDRESS p /� Q )Q �/ COWiECTION DAJA
CITY SD NO. Q�/1P I BTATION 7
// STATE U
REGISTRATION NO. T COUNTY MANHOLE R[!<[R[NC[ LOWER
ND. DESCRIPTION OF WORK FEE TYPE OF CONNECTIONLENGTH FROM
HOUSE SEWER
CONNECTING TO Y. CURB P,L. M,L.TO P.L.
I PUBLIC SEWER j5.GO
6 IC TANK.SEEPAGE PI7 OR ibis
NO.
PITS AND/QR DRAINFIELD f $10.00 CO.IMP.NO. b6 NO.
I HOUSE°EWER CONNECTING TO
PRIVATE DISPOSAL■YSTIM $°,00 TRUNK PERMIT O. ROAD PERMIT NO.
CONNECT ADQITION'AL BLDG.OR AFFIDAVIT SA7F[[ wu[R RECORD.INfTR,NO, PATI
WORK TO HOUSE°EWER
OVERFLOW SEEPAOtl PIT.D AINFIELD
[XTN.,CEDSPOOL,DRYWELLMANHOL[0 *5.00 HWY.OR fT.WID[NIN
AL R,R AIR OR ABANDON HOU@ . Q
SEWER OR DISPOSAL SYSTEM I $3.00
/TATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WAST[APPROVAL
O,Y 11^1,�^ CH ARG[S
L.II 3 PERMIT i 2 00
AUTHORMATION I TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THi■ DAT[ A CONTRACT WITH THE HEREIN NAMtO CON-
REIMSU Ro EM[NT FI[
TRACTOR TO CONNECT THE ABOVE DESCRIBED LAISTING DW LLLING
TO THE PUBLIC *EWER. AMOVAT Q QAT[ INSPECTOR'@ SIGNATURE
SIGNED THIS DAY OF 1D
OWN"OR NFW HOUSE @EWER
OWNERS AGENT
CORRECT ADDITIONAL
ADDRESSBUILDIP40 OR WORK 7�
fQTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFI[4D
AND STAT[ THAT THEABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAW* REGULATING CESSPOOL ❑ DRYW ELL �I
PLUMBING AND SEWERS. Q
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LIC[NflD Al R[OUIRID BY LOf ANG LU COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESI D[ IN, TH11�ABKSCRISIKD RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF PQiM BACKFILL SEPTIC T1ANK- ❑ V
SEEP,PIT ff) ❑ I.ESSPOO L* JU
y'
(gAI, AIION RQ E A. W D
M.O. CASH
SUPERVISING MECHANICAL ENGINEER
CK.
L"4 6 4 4Q; SEP21 1 O H 5.00 q
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