HomeMy Public PortalAbout5752 CAMELLIA AVE_Sewer__ 642D
76A642 0-63 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FAODRESS
ING
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Supt of Building
iTYSTFOR APPLICANT TO FILL IN ST.
LEGAL �v//
DESCRIPTION LOT NO � OWNER
MAIL
BLOCK TRACT ADDRES
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT 3 CITY TEL. NO.
... OF
DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
' BK PG /
CONTRACTOR '� IL� E7
ADDRESS CONNECTION DATA
STATION DEPTH
CITY TEL. NO.
❑ STATE UPPER
REGISTRATION NO. ❑ COUNTY MANHOLE REFERENCE LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. a
PUBLIC SEWER @ $5.00 p,C.NO. O
SEPTIC TANK,SEEPAGE PIT OR CO.IMP.NO. JOB NO.
PITS AND/OR DRAINFIELD @ $10.00 V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. GC
PRIVATE DISPOSAL SYSTEM @ $3.00 O
CONNECT ADDITIONAL AFFIDAVIT I WIIIY111 I 11151N1NT RECORD.INSTR.NO. DATE 1.
WORK TO HOUSE SEWER @ $3.00 U
OVERFLOW SEEPAGE PIT,DRAINFIELD NJ
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00 a
HWY.OR 5T.WIDENING H
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT
PERMIT NO. C� �•`-1.2�
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT s 2 00 CHARGES
AUTHORIZATION TOTAL FEE 00 CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY FIft 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR�C
ADDRESS SEPTIC TANK,SEEP,PIT(S)
1 HEREBY AC OWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY -
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND SEWERS. CESSPOOL [IDRYWELL
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THA 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A O E DESCRIBE RNTIAL�PROPERTY. ABANDON HOUSE SEWER
SIGNATURE cnE BACKFILL SEPTIC TANKS ❑
OF PERMITTE12" SEEP,PITS) ❑ CESSPOOLS ❑
VALIDATION ROBERT WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
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