HomeMy Public PortalAbout5204 DALEVIEW AVE_Sewer__ AG42II-95
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SAPPLICATION FOR PERMIT
9
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of Couptp Engineer - -
County of Los Angeles BIIILDING ` a i{a.Lw�
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS J ,
.
CASSATT D. GRIFFIN, SUPT of Bu1Lm_ LOCALITY
® I ,....- NEAREST �, J
FOR APPLICANT TO FILL IN CROSS ST iYf/1N..(
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT 1!v0a 0 ADDRESSNo '
SIZE OF LOT�P7e{ NOW ON LOTS CITY T ` TEL. NO. i((•
USE
BUILDINGS DISTRICT NO. GROUP MAP
��` BK PG
a CONTRACTOR _ t
ADDRESS a� -(/yL4.1� CONNECTION DATA
'O U J STATION DEPTH '
CITY TEL. NO. /j'L T/y
MANHOLE REFERENCE p
_ ,K STATE �/ 7/JQ LOWER
REGISTRATION NO. 1"/�� ❑ COUNTY ,
NO. _ DESCRIPTION OF WORK FEE
1 HOUSE SEWER CONNECTING TO TYPE OF CO N NECTIOZg� LENGTH FROM y
PUBLIC SEWER @ $3t50 Y. CURB �r.�� M.L.TO P.L. CJy J
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD (3 $ 3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN_CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. NO. JOB N0.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $.1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER (D $ 1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1.00 WASTE APPROVAL '
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT S 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
' I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING q
TO THE PUBLIC SEWER. (/ NEW HOUSE SEWER L ,
SIGNED THISDAY � 79�]2 [ory NECT ADDITIONAL
OWNER OR n \ BUILDING OR WORK -
OWNERS AGE NTd SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR GRAINFIELD
IH
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
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR AND
DISCONNECT PLUG
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HO PLUGUSE D
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE —
ER
DESCRIBED RESIDENTIAL PROPER BACKFILL SEPTIC TANKS❑
(�j SEEP. PITS) El CESSPOOLS,d
SIGNATURE ///
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ' ROBERT A. WOOD. CHIEF PLEIG. INSPECTOR, \.
L
o s s .6 A JA� 5;
ADD
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