HomeMy Public PortalAbout5211 DEGAS AVE_Sewer__ 6A642 -E4
7 D APPLICATION FO PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER _
BUILDING AND SAFETY DIVISION BUILDING /
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN. Sup't of Building h
LOCALITY
NEAR
FOR APPLICANT TO FILL IN CROSS ST.
EGAL
DESCRIPTION LOT NO. L OWNER L�
C.� /''''J MA IL
BLOCK TRACT y[ fJ CS ADDRESS
NO. OF BLDGS,
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTOR �5r' p ry
ADDRESS CONNECTION DATA
CITY TEL. NO. S STATION Y DEPTH
STATE /] / UPPER
REGISTRATION NO. /4...1 /_9 D COUNTY. MANHOLEE REFERENCE
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION d LENGTH FROM
iy HOUSE SEWER CONNECTING TO Y. CURB .L. M.L.TO P.L. CJ
PUBLIC SEWER 55.00 p,0.NO. Y'
SEPTIC TANK.SEEPAGE PIT OR CO.IMP. NO. JOB NO, } �'
PITS AND/OR DRAINFIELD ® SIO.00 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. U
PRIVATE DISPOSAL SYSTEM C41 53.00
CONN ECT ADDITIONAL BLDG.OR AFFIDAVITAIV S[R[ RE CORD.INSTR.NO. DATE
.0
WORK TO HOUSE SEWER 530 O
OVERFLOW SEEPAGE PIT.DRAINFIELD K [X [1 V
EXTN..0 ES SPOOL.DRYWELL.MANHOLES5.00 W
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING y
SEWER OR DISPOSAL SYSTEM 53.00 STATE ENCROACHMENT Z
PERMIT NO.
INDUSTRIAL
[Eq
WASTE APPROVAL
CHARGES
OWNERS PERMIT4 z o0
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
Y HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DES( IBE, EXISTING DWELLING
TO THE PUBLIC 5EW APPROVALS DATE INSPECTOR'5 SIGNATURE
SIGNED THIS DAY OF 19� _ p
OWNER OR NEW HOUSE SEWER
OWNERS AGENT- CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP.MITIS)
IH
ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ANO/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 AB ESCRISEO R EROPERTY. ABANDON HOUSE SEWER
SIGNATURE ❑
OF PERMITTEE BACKFILL SEPTIC TANKS
SEE'.PIT IS) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK
M.0. CASH
L,'S o 1 7 0 1:o MAY 17 1 0 D 7.0 G