HomeMy Public PortalAbout5026 DALEVIEW AVE_Sewer__ 6
5&E-G63 3.95 APPLICATION 'FOR PERMIT tory
5&E.6
DIVISION OF BUMDING AND SAFETY SEWER—SEWAGE DISPOSAL �L
Department of County Engineer -
County of Los Angeles BUILDING .
WM.J. FOX. COUNTY ENGINEER, ADDRESS
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY �� A
FOR APPLICANT TO FILL IN NEARESTCROSS
LEGAL
DESCRIPTION LOT NO. /G OWNER
BLOCK TRACT /6Q�a MAIL
L ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT USECITY TEL.
N0.
OF
F
NGS DISTRICT NO. GROUP MAP
BK PG
•
CONTRACTOR J, � a CLQ
ADDRESS 3� 0 CONNECTION DATA
CITY STATION �L�� DEPTH ,
STATE MANHOLE REFERENCE /J S UPPER
REGISTR ON ❑ COUNTY
No. DESCRIPTION OF WORK FEE
TYPE OF CONNECTIO LENGTH 'ROM
LHOUSE SEWER CONNECTING TO Y. CURB M,L. TO P.L. 2
PUBLIC SEWER ® S 3.50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 _ J y
WORKECT TO HOUSE SIEWER BLDG.AL OR 1.00 ' CO. IRP. NO. 1M 3_J P C N.
OBN O
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM I.00 TRUNK PERMIT NO. ROAD PERMIT NO.
1 DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD .00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
PERMIT CONNECTION CHARGE FEE
OWNER'S s 00
AUTHORIZATION I TOTAL FEE /w REIMBURSEMENT FEE
TRACTOR HAVE TTOS CONNECTDATE O THEAABOVECTED WDESCRIBEDITH THE H EX STINGEREIN AMED DWELL AG APPROVALS DATE INSPECTORSSIGNATURE
TO THE PUBLIC SEWER -
SIGNED THIS 'I'0—DAY F 1y,'�L NEN HOUSE SEWER _,A8.
OWNER ORCONNECT ADDITIONAL
W
ONERS AGENT~ BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESSIrr'l F AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE 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 COUNTY A D STATE OF
CALIFORNIA O THAT I THE L AL OWNER THE B E ANDON HOUSE SEWER
DESCRI D RE N ROPERTY. ACKFILL SEPTIC TANKS❑ q �/
t ! y Q� EEP. PIT I51 ❑ CESSPOOLS m SU'�1�Jy IY
SSSI NATURE
OF PERMITTEE
WILLIAM J. FOX.COUNTY ENGINEER VALIDATION R:.A.WOOD, CHIEF PLBG. INSPECTOR