HomeMy Public PortalAbout5202 DALEVIEW AVE_Sewer__ Ae42642b p ✓� APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deportment of County Engineer rDl
County of Los Angeles G rte]JOHN A. LAMBIE. COUNTY ENGINEERS J d�CASSATT O. GRIFFIN, SUP'T oF BUILOiNG TY
FOR APPLICANT TO FILL IN caoss si. �L e�t/I p
LEGAL OWNER -
DESCRIPTION LOT N0. '
q MAIL
BLOCK TRACT I SLO AD ADDRESS (-ate
{) NO. OF SLDGS. CITY /,J• TEL. NO. /J ✓9
SIZE OF LOT UX NOW ON LOT l /
USE OF .-...-. _ .. .-_
' BUILDINGS �� DISTRICT NO. GROUP MAP
BK P'CONTRACTOR
.ADDRESS CONNECTIONS DATA �c
CITY i TEL. N0..,,L STATION DEPTH
MANHOLE REFERENCE UPPER -
REGISTRATION N0, STATE LOWER S 1 " ❑ COUNTY
NO. DESCRIPTION OF WORK FEE 1
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
Y- CURE P.L. M.L. TO P,L.
HOUSE SEWER - -@ $3.50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/O RDRAINFIELD @ g 3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. NO.
EXTN..CESSPOOL,DRYWELL,MANHOL E.n s Z.00 CO. IMP. NO, JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ g 1.00 TRUNK PERMIT NO. ROAD PERMIT NO. -
CONNECTADDITIONALBLDG.OR (� STATE ENCROACHMENT
WORK TO HOUSE SEWER a. $ L00 "' PERMIT NO.
ALTER.REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM n- S 1.00 WASTE APPROVAL -
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 ]ABOVE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH-THE HEREIN NAMEAPPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWE
TO THE PUBLIC SEWER. [/y/'',�.{y�`'�/ /� NEW HOUSE SEWER
SIGNED THIS /nVAi�riii����Y S 19 CONNECT ADDITIONAL _
OWNER OR .,.�/ /' �1 C]/ BUILDING OR WORK
OWNERS AGENT /- 1/ ` SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICCESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO C
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGUALTER.REPAIR,SEWER OR.
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
-I HEREBY CERTIFY.THAT i AM PROPERLY REGISTERED ADISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STADISCABANONNECT
HO PLUGAUSE D
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE DESCRIBED RESIDENTIAL PROP RTY. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A. WOOD. CHIEF PLBG. INSPECTOR
CK. N,0. -
� bO:26-'7- APR 25-' .q A 2:00 ' ?