HomeMy Public PortalAbout5214 DALEVIEW AVE_Sewer__ 76A842OAPPLICATION FOR PERMIT.
6 6 E-669 1 1.55
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer - -
- - County of Los Angeles =LADDRESS
JOHN A. LAMBIE, COUNTY ENGINEER CASSATT G. GRIFFIN, SUPT OF BUILDING
FOR APPLICANT TO FILL IN cross si.
LEGAL OWNER
DESCRIPTION LOT N0.
BLOCK TRACT ZQ DGS.
MAIL -
ADDRESS
A NO. OF BL
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS
DISTRICT NO. GROUP MAP
BpILDINGs !�/'
C/ r✓ BK 1P�
CONTRACTOR
ADDRESS �
•� CONNECTION DATA
CITY EL. NO. STATION / U DEPTH /
.. /
MANHOLE REFERENCE. ../'51� UPPER-
REGISTRATION N0 ❑ COUNTY .
NO. DESCRIPTION AORK FEE
TYPE OF CONNECTIO LENGTH FRM ✓qq }�
74 HOUSE SEWER CONNECTING TO yP:L.Y. CURB M.L.TO P.L.Or .7
PUBLIC SEWER @ b3.50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEOL.GEPIT, DR AIN HOLEXTN. E
CO. IMP. NO. ��Q ,7 JOB NNO
OVERFLOW
OW SEEPAGE
YWELL,MAN ISLE @ $2.00
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 @ b I.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE - INDUSTRIAL
SEWER OR DISPOSALSYSTEM@ $L00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT t 60
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
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS /5' DAYOF ���/ G 9'r'� CONNECT AOOITIONAL
OWNER OR �SS /./yLfeaeU BUILDING OR WORK
OWNERS AGGENT /J _ SEPTIC TANK,SEEP, PIT(S)
AND
_ ADDRESS ai"9'LE�%E/•f/ �kN/ �� /OR OaAINFIELD
-I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL D "
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 CONNECT PLUG AND
LICENSED AS REQUIRED Y LOS ANGELES COUNTY AND STATE F A ON HO PLUGAUSE D
CALIFORNIA OR THAT I AM E L ER OF A
DESCRIBED E IAL P FI LL SEPTIC TANKS❑ i' )`
SIGNATURE / r, E4.PIT(S)D CESSPOOLS, �r /vim �/
OF PERMIYYYYYYTTTTTTCCCCCCE -
JOHN A. LAMBIE. COUNTY ENGINEER. VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. N. 0, p5X
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