HomeMy Public PortalAbout5226 DEGAS AVE_Sewer__ EERBB 3-E4 0 APPLICATION FOR PERMIT �I
E80B u
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
]M A. LAMHLE. County Engineer ADD
WILLIAM A. JENSEN. Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
EGAL
OESCRI PTION LOT NO. OWNER
MAIL
BLOCK TR4CT S^(p ADORES$ all
NO. OF BLDG..
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP BK
MAP �OCESSED BY
BUILDINGS
/ _ PG
CONTRACTOR
ADDRESS lgoig, CONNECTION DATA
CITY L. NO. 1 STATION `� DEPTH
JUPPER
qq '$TATE MANHOLE REFERENCE `�
REGISTRATION NO. �a ❑ COUNTY _ k v• COIF
NO. 1 DESCRIPTIO OF WORK FEETYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO —. Y. CURB
P.L. M.L.TO P.L.
PUBLIC SEWER ® S5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. }/ }
PITS AND/OR GRAINFIELD ® SI0.00 CO.IMP. NO. JOB NO. �/ O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. 0
PRIVATE DISPOSAL SYSTEM ® $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIY[II N..NKNNT RECORD. I=ATE
DATE C
WORK TO HOUSE SEWER ® S3.00 O
OVERFLOW SEEPAGE PIT.GRAINFIELD ~
EXTN..CESSPOOL,DRYWELL,MANHOLEQ S3.00 HW YOR STWIDENING W
ALTER.REPAIR OR ABANDON HOUSE Y. . d
SEWER OR DISPOSAL SYSTEM ® $3.00 STATE ENCROACHMENT N
PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIC s z o0
AUTHORIZATION TOTAL FEE ' CONNECTION CHARGE FEE
'I HAVE AT THIS DATE ACONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PU L'CSEWE,1,,j APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS AY OF _I9
OWNER OI NEW HOUSE SEWER {
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC1 MEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AN./OR
TANK.SF.EL. TIS)
ANO/OR DRAINFIELD
AND .TATE THAT THE ABOVE ILAND AGgEE E COMPLY
WITH ALL COUNTY ORDINANCES
AND SS ANO STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYW ELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABO ESCRISED RES L PROPERT ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANK$ ❑
OF PERMITTEE SEEP.PITISI ❑ CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
UlcK M.o. CASH SUPERVISING MECHANICAL ENGINEER
M,0. CASH
ACO 1 7 0 8 MAY 17 1 O D 7.0 0~ r