HomeMy Public PortalAbout6127 CAMELLIA AVE_Sewer__ i
f79 • 1130. ` APPLICATION FOR PERMIT
` couNTY OF LOS ANGELES SEWER—SEWAG ISPOSAL
DEPARTMENT OF COUNTT EN(3INEEB
Bu .DIN(; AND.SAFETY bIVIBION BUILDING
GHN JL i.[[OM ADDRESS
Wn I.uM A. JEKSM.
LOCALITY C
FOR APPLICANT TO FILL IN `R°°' ST.AL
DES='IOH LOT NO. OWNER I ✓
MAIL
BLOCK TRACT ADD—@
NO. OF BLDG•. '7
SIZE OF LOT � MbW ON LOT / CITY
USE OF DISTRICT NO OR MAS BY
pUILDING■f pK PO
CONTRACTOR D ,
ADDRESS CONNECTION DATA
CITY TEL. NO.
STATION DEPTH
ATE MANHOLE REFERENCE
REGISTRATION NO. STATE
LOWER qo.
No. DESCRIPTION OF WORK FIE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L M,L TO P.'L V
PUISLIC SEWER $5.00
F.C.NO.
• IC YANK.SXXPAGE FIT OR
I.ITS
AND/OR R
DAINFI[LD � 8I0.00
CO.IMF.NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOBAL SYSTEM SE.00
CONNECT ADDITI0 A AFFIDAVIT SAI"■I ""II[JT RECORD.INSTR.NO. DATE
WORK TO HOUSE■ SE.00
OVERFLOW•[[PAGE FIT.DRAINFIELD
EXTN.,CE/JPOOL,DRYWELL,MANHOL[ $5.00
AL .R ARO AWA DO O HWY.OR ST.WIDENING
SEW[R OR DISPOSAL SYSTEM 12.00 STATE XNCROACHMQNT
PERMIT NO.
INDUSTRIAL t
WAST[APPROVAL
OWNEWS PEEM T $ 2 00 1 CA
CONNECTION CHAROE FEE
AOTHORIZATTON TOTAL FEE
1 HAVE AT THIS DATE A CONTRACTTC
WITH H[ HEREIN NAMED ON- Mill MBUR1[M[NT FII
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWE.LING n Ta
TO THE PUSLIC ■EWER. - AMOVAU DAT[ INSPE 10 R[
SIGNED THIN DAY OF _19—
OWNER
9_OWNER OR NEW HOUSE SEWER
OW11[R2 AO[HT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
■DTIC TANK.SEEP,PTT(S) �}I.
I HEREBY ACKNIA
OWIDG[ THAT I HAVE RED THIS APPLICATION AND/OR DRAINFIELD J l
ANR STAT[ THAT THE AISQVE I• CORRECT AND AGR[[ TO COMPLY
WITH ALL COUNTY ORDINANCE• AND STAT[ LAWS REGULATING CESSPOOL ❑ DRYWELI. El �y
PLUMPING AND SEW[R!.
1 HEREBY CERTIFY THAT IAN PROPERLY RIGIST[RED AND/OR AL77R,REPAIR.•EWER OR
LI CXNBED AS REQUIRED 19TY
ANGLES COUNTY AND STATE OF SEWAGE DISPOiAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
REBID[ IN, THE ABOVE PKSCRIBtD R[SID[ AL PROPERTY. ABANDON HOUSE SEWER
SIGNATUREs�� BAC"ILL■EPTJ_C TAN" ❑
OF PERMITTEE C�J(L,�Q BE".PIT(S) LJ CEMPOOLB
VALIDATTQN' __-) ROBERT A WOOD
CK. M.O. CASH
( i SUPERVISING MECHANICAL WOINEER
Lfij� 3408JUL 71- OD 5.00
CANCELLED AT Rtyt.�L'i �jf PERMITTEE