HomeMy Public PortalAbout5124 DALEVIEW AVE_Sewer__ 76AX42OB� APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT.OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING /
JOHN A. LAMBIE, County Engineer ADDRESS ///E
WILLIAM A. JENSEN, SLP't of Building �_
LOCALITY
NEwREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT J (/ Z> ADORES'
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT 'CITY TEL. NO.
USE OF
BUILDINGS DISTRICTNO. GROyH MAP PROCESSED BY
PG
1� G' - / 0
CONTRACTOR j
ADDRESS �' J /g S ' CONNECTION DATA
C)
/_V.L�O DEPTH
CITY TEL. NO. V �F`/-
" STATION
❑ STATE UPP
REGISTRATION NO. I o ElCOUNTY MANHOLE REFERENCE
NO. I DESCRIPTION OF WORK EEE TYPEOFCONNECTI LENGTHFRO }
HOBLICSEWERCONNECTINGTO @ 3500 lin Y. CURB P.L. M.L.TO P,L. J O
SEPTIC TANK.SEEPAGE PIT OR L >/ P.0 NO. V
PITS AND/OR GRAINFIELD SIOOO CO. P.
NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. gOAD PERMIT NO, n
PRIVATE DISPOSAL SYSTEM $3.00 Riy Ascn[x
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT 'R ECORO.INSTR.NO. DATE
WORK TOHOUSE SEWER
@ $3.00 ''E ER F
OVERFLOW SEEP4 GE PIT,GRAINFIELD
FXTN.,CESSPOOL.ORYWELL.MANHOLE@ 35.00
ALTER,REPAIR OR ABANDON HOUSE OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ S3.00 -ENCROACHMENT
PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT 3 z 00
CONNECTION CHARGE FEE CHARGES
AVfHORIZATION I TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN Np MED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_ r
OWNER OR /)/) NEW HOUSE
OWNERS AGENT_ /�{!�y CONNECTADDITIONAL
DORE55
✓ .l BUILDING OR WORK
SEPTIC TANK.SEEP PIT(S)
HEREBY ACKNOWLEDGE THAT 'I HAVE HEAD APPLICATION AND/OR GRAINFIELD
ANO STATE THAT THE ABOVE ICORRECT AND AGREE
E COMPLY
WITH ALL COUNTY ORDINANCEE S AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYWELL ❑
1 HEREBY CERTIFY THAT 1 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 O IRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER L
SIGNATURE
OF PERMITTEE_ B XCHFILL SEPTIC TANKS ❑
SEEP.PITISI ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
CK. M.0. CASH
SUPERVISING MECHANICAL ENGINEER.
GJ,CO 0 4 2 9:L JAN 31 1 0 0 7.0 0