HomeMy Public PortalAbout5216 DALEVIEW AVE_Sewer__ CEBOatS APPLICATION FOR PERMIT- 2/�Xl_ —�
CEBOBfB-Ee
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER, - . ..
BUILDING AND SAFETY DIVISION BUILDING
AO DRESS 1 /G 1/ C w
IGRN A. LANffiIE. County. Engineer - r
CASSATT D. GRIFFIN, Supt of Building LOCALITY C P 1 2
' NEAREST ;,
FOR APPLICANT TO FILL IN CROSS ST. r
LEGAL
DESCRIPTION LOT NO. D OWNER Z jv� 01' 2 el
MAIL
BLOCK TRACT �O D ADDRESS
.i " OFBLDGS.
SIZE OF LOT V NOW ON LOT CITY C L. NO.
USE OF
BUILDINGS Ir to el C DISTRICT NO. I MAP PROCESSED BY
BK PG
CONTRACTOR
ADDRESS G ��-�Jl----- CONNECTION DATA
CITY �u U C( TEL.NO. 1- STATION DEPTH
TATE MANHOLE REFERENCE UPPER
REGISTRATION NO. �� Q� COUNTY .. LOWER
NO. I ;R"TIDN OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION : LENGTH FROM
SEPTIC TANK. SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ S3.00 r
OVERFLOW SEEPAGE PIT.DRAINFIELD 0 3
p E%TN..CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ SI.00 bT TRUNK PERMIT N0. ROAD PERMIT N0. -
A LT ER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 3100 REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CO%
TRACTOR TO CONNECT THE ABOVE DESCRIBED E%IST NG DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEV
SIGNED THI Y OF 90 NEW HOUSE SEWER
OWNER OR -- CONNECT ADDITIONAL ••tt�
OWNERS AG NTSBUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP. PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAY AD THIS APPLICATION
AND STATE THAT THE ABOVE IS CORK AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR.SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REOUI RED BY LOS ANGELES COUNTY AND STATE OF r ABANDONCT PLUGA HOUSE D
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
ER
DESCRIBED RESIDENTIAL PROPER BACKFILLSEPTIC TANKS ❑
SIGNATURE
SEEP.PITS) ❑ CESSPOOLS ❑
OF PERMITTE YGQ!i/
®' VALIDATION ROBERT A. WOOD
K,
CM.O. r•= SUPERVISING MECHANICAL. ENGINEER
!.}t(,o97 .62S. APR2510A 3.00