HomeMy Public PortalAbout5024 DALEVIEW AVE_Sewer__ 5&eE-6669 13 11-59 APPLICATION FOR PERMIT
S 6.
DIVISION OF BUILDING AND SAFETY SEWER 'SEWAGE DISPOSAL
Department of .County Engineer -
-- County of Los Angeles 9UTLDTNG
.JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT 0. GRIFFIN, SUPT OV BUILDING LOCALITYNEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGALI I'] OWNER '
DESCRIPTION LOT N0, I
MAIL
BLOCK TRACT ADDRESS
�NO. OF BLOCS. CITY N0.
- SIZE OF LOT (/ NOW ON LOT
USE OF
BUILDINGS - DISTRICT N0. G UP MAP
5 `� BK PG
CONTRACTOR . (, - lb1 z:
(�-
CONNECTION DATA b
ADDRESS STATION �j T17 DEPTH 6 f
CITY TEL.
MANHOLE REFERENCE ^ UPPER
L1 STATE 1 (�
REGISTRATION NO. ❑ COUNTY
NO. DESCRIPTION OF WORv EE TYPE OF CONNECTIO LENGTH FRO
' HOUSE SEWER CONNECTING TO ^ Y- CURB �.L. M.L.TO P. M
L. ` j;�j
PUBLIC SEWER @ $3.50
3 SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR GRAINFIELD Q $3.00 /
OVERFLOW SEEPAGE PIT.GRAINFIELD N0. -
EXTN.,CESSPOOL,DRYWELL,MANHOLE C4 $2.00 CO. IMP. NO. 'O �J JOD NO.
HOUSE SEWER CONNECTING TO ,
PRIVATE DISPOSAL SYSTEM Q $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER Q $1.00 V PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1.00 WASTE APPROVAL
- CHARGES
CONNECTION CHARGE FEE -
OWNER'S PERMIT $ 00
REIMBURSEMENT FEE
AUTHORIZATION• TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTORSSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. - NEW HOUSE SEWER i
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD - -
I HEREBY AC NO.L DG*HA AVE RE T IS APPLICATION CESSPOOL❑ ORYWELL❑
AND STATE THAT THE ABOVE 15 CORRECT D AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STA LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM -
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COU TY AND STATE OF DISCONNECT
PLUGABANDON HOUSE A D
CALIFORNIA OR THAT I AM THE LEGAL 0 ER OF THE {�B VE
DESCRIBED RESIDENTIA PERTY / BACKFILL SEPTIC TANKS❑
SIGNATURE
SEEP. PIT(51 ❑ CESSPOOLS❑
OF PERMITTEE
JOHN A. LAMBIE. COUNTYa GINEER VALIDAT' O ROBERT A.WOOD, CHIEF PLBG. INSPECTOR
CK.
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