HomeMy Public PortalAbout5828 CAMELLIA AVE_Sewer__ CE8°81
76A642D 0-63 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ."
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST �`
FOR APPLICANT TO FILL IN CRoss Br. V
tAS
LEGAL Al
DESCRIPTION LOT NO. OWNER
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BLOCK TRACT ADDRESS I
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
Jam// BK PG
CONTRACTOR AjTG� y
ADDRESS (o _ CONNECTION DATA
CITY M, TEL. NO. A.7, STATION DEPTH
fl 40 qn/ STATE MANHOLE REFERENCE
REGISTRATION NO. / COUNTY (` , t;71,fLOWER
NO. DESCRIPTION OF WORK FEE TYPE OF ON NECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. URB P.L. M.L.TO P.L. s
PUBLIC SEWER @ $5.00 /�� A p,C.NO. O
SEPTIC TANK,SEEPAGE PIT OR CO.IMP.NO. / u JOB NO.
PITS AND/OR DRAINFIELD $10.00 V
HOUSE SEWER CONNECTING TOTRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ 53.00 0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIV[R [A..... RECORD. INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD 11.1
EXTN.'CESSPOOL,DRYWELL.MANHOLE @ $5.00 a
HWY.OR ST.WIDENING h
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $3.00STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 2 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
'IHAVE 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 OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE 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 ❑ DRYWELL ❑
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 THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED IDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
SEEP.PIT(5) ❑ CESSPOOLS
VALMIDATION ROBERT A. WOOD
CASH
SUPERVISING MECHANICAL ENGINEER
CK. .O.
1 5 5 1 JLIL 18 1 ^ D 5.0 C0 N dl
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