HomeMy Public PortalAbout5812 CAMELLIA AVE_Sewer__ "'W14 sa a.ss
APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY S EW E Fh-S SWAGE DISPOSAL '
Dopmtment of Com Ea-facer
Co=tp of Los �M FUl GWM.J. !•OX.COUNTY QNammtCASBATT M G UMN.SUrr QF IlUum na FOE APPLICANT TO FILL IN OSS ST. _15016 ve
LEGAL
DESCRIPTION LOT NO. OI/SER
BLOCK TRACT MAIL
ADDRESS
NO. OF BLDGS.
SIZE OF LOT Now ON LOT CITY THL. XO
USE OF
BUILDINGS DISTRICT NO. GROUP YAP
e PG
CONTRACTOR
ADDRESS •-
CON]G=OF DATA
CITY TEL. NO. ON DEPTH
❑ STATE ANHOLE R FERENCE c
REGISTRATION NO. 3 �.J
No. DESCRIPTION OF WORK FEE
TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y L. TO FROM
PUBLIC SEVER 3.50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. ORP. C. NO,
WORK TO HOUSE SEWER 1.00 CO. IIiP X0. JOB NO.
ALTER OR REPADISPOSAL
EXISTINGLSYSTTRUNK PERMIT NO. ROAD PERMIT X0.
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AMD/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK,SEEPAGE PIT OR INDUSTRIAL
PITS AND/OR DRAIXFIELD .00 WASTE APPROV
ALL
CESSPOOL-DRYWELL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
0��8 PEBMrT S 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMEICT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NA ED CON- Mp
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DIVELLIXG AOVALS DATE 1 SFECTO �S SIGNATURE
TO THE PUBLIC S[WER
SIGNED Tlil 19_ NEW HOUSE SEWER
CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGEIIT
SEPTIC TANK,SEEP, PIT(S)
ADDRES AND/OR DRAINFIELD '
I HEREBY ACKNOW DG¢ HAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYW¢LL❑
/A11I��D STATE THAT THE ABOVE IS CORRECT AND AGREE TQ COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR,SEWER OR
PLUMBING AND SKIVERS. SEWAd¢DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR
LICENSED AS R[OUIRffi BY LOS ANGELES CO AND STATIC OF DISCONNECT PLUG AND
CALIFORNIAOM THA I AN THK GAL F THE ABOVE ABANDON HOUSE SEWER
D[SCBJBILD X ID PBO CSFILL SEMC TANKS
jz..r,PM8I,U CEszPOO
SISIIIITUN!< �Q � �► �/
OF FEIt1 J
Wiu..LkU..FOX.Couxrr KMMK& VAMATMN Pe.A.WOOD, CHIKF Pua. IIN,P It
8 0 5 1 WAY 1 1 4
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:: ,,.� APPLICATION FOR PERMIT
DIVISION OF BURDINO AND SAFETY SEWER--SEWAGE D 1 S POSA L
D.post-mt of County F- i— /
County of Los An"les BUD >� / ~
JOHN A. LAMBIE COUNTY ENGINEER
C kg"TT D.4RIFFIN, BUr•T OF BU,LDINO LOCALITYREAREEIT
FOR APPLICANT TO FELL IN CROSS ST.
LEGAL OWNER
LOT NO.
IAIL
BLOCK TRACT ADDRF�S
WO. OF BL.DGB. 4FCITY TEL. NO.
SIZY OF LOT NOW ON LOT
BUIgag]
USELDINGS
OF DISTRICT XO.. GRO P YAP
BUILDIRGS PG
CONTRACTO ��
ADDRESS CONNF.MON DATA
OX DEPTH
CITY
TEL No.
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❑ STATE YAIiHO{Q PEIER
CE PPER
REGISTRATION XO.
411
�
NG. DESCRIPTI N OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CORNECTIOR LENGTH FROM �-
PUBLIC eEWER 3.50
Y.L.TO P.L.
SEPTIC TANK.SEEPAGE PIT OR
PITS AMD/OR DRAINFIELD e f 3.00
OVERFLOW SEEPAGE PIT,DRAIN FIELD P. C. R0.
EXTN.,CESSPOOL DRYWELL MANHOLE 2.00 CO. IMP. NO. ]OB O.
HOUSE SIEWER CORNECTINB TO
PRIVATE DIS SAL SYSTEM Q f 1.00 TRUNK PERMIT R0. ROAD PERMIT NO.9,0
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER f L00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE IXDUSTRI*L
SEWER OR DISPOSAL SYSTEM1.00 WASTE APPROYAL -
CHARGES
CONRECTION CHARGE FEE
owutws Fmmn
-6-
AUTHORIZATION TOTAL FES REIMBURBEMERT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPRQVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTIRG DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THI 19 CONNECT ADDITIONAL
OWNER OR BUILIPING OR WORK
OWNERS AG SEPTIC TANK,SEEP,PIT(SJ
ADDRESS ! ARD/OR DRAINFIEL.D
1 HEREBY AC"OWLEfbGE THAT I HAVE READ THIS APPLICATION CESSPOOL Q DRYWELL❑
AN-D STATE THAT THE ABOVE 18 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HERESY CERTIFY THAT 1 AY PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES AND STATE OF DISCONNECT PLUGAND
ABANDON HOUSE SAND
CALIFORNIA OR THAT I AN THE CA WN THE ABOVE
EWER
DESCRIBED RESIDENT ROP BACKFILL SEPTIC TANKS❑
SIGNATURE t P.PIT(S) CPVLS
OF PERYI
O
JOHN A. LAMBIE, COUNTY ENOINKER Aj,IDATION ROBERT A.WOOD, Cryl[P'PLSO. INGP[CTOR
CC. ■.0. C"N
�o a 0 5 2 MAY 1.,1 5 - 25-00 'o
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