HomeMy Public PortalAbout5219 DOREEN AVE_Sewer__ 6A64 10-63 APPLICATION FOR PERMI
C EB08 1
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILD I"' ��/
JOHN A. LAMBIE, County Engineer ADOFESs
WILLIAM A. IENSEN. Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
OESCR PT ON LOT NO. T� ?j�[f OWNER
MAIL
BLOCK TRACT //� ADDRESS
OF SLOGS.
SIZE OF LOT NOW ON LOT / CITY TEL. NO.
USE OF �J
BU ILDINGS���P���f�J DISTR/I�C1T NO. GROVP MAP jjII PROC $SED BY
�S K �GCJ
CONTRACTOR C/. Gog-L�crn
ADDRESS
.��/,�C) 1141, CJJL�L� CONNECTION DATA
CITY .- eAy/%16,(�-,IE TEL. NO. Y" v- 713 STATION DEPTH
[.]STATE MANHOLE REFERENCE OFFER
REGISTRATION NO, ���`'�¢ El COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CV RB P.L. M.L.TO P.L. Y
PVBLIC SEWER55.00 O
P.C. NO.
SEPTIC TANK.SEEPAGE PIT OR CO.IMP.NO. JOB NO, j� V
PITS qND/OR GRAINFIELD � 510.00 "
HOU EE SEWER CONNECTING TO I 1
TRUNK PERMIT NO. ROAD PERMIT NO.� /� ` C
PRIVATE DISPOSAL SYSTEM @ $3.00
\ / V
CONNECT ADDITIONALBLDG.OR AFFIDAVIT [45[M[xi RECORD.IN$TR.NOI t
WORKHOUSE 5300
OVlBFL.W G
SEEPAGE PIT,L,MANHOLE
/ W
E%TN., (i
P �.L,ORYW ELL,MANHOMOLE @ $5.00 03
i/ 'RtiPR,REPAIR R-ABAMEOIi SE
HWY. OR BT.WIDENING
SWFFN OSAL SYSTEM ® $3.00 O O STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT sl rzl DD CHARGES
AUTHORIZATION TOTAL FEE V Cd ONNECTION CHARGE FEE
'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'$SIGNATURE
SIGNED THIS DAY OF 19
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECTADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TAIK.SEEP.GRAINFIEL PIT(S)
1 HEREBY ACKNOWLEDGE THE
E IS HAVE HEAD THIS APPLICATION gryplOR GRAINFIELD
AND STATE THAT TME ABOVE IS CORRECT AND AGREE E COMPLY
WITH ALL COUNTY
ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYW ELL ❑
LICHEREBY CERTIFY THAT 1
FREED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGAM PROPERLY REGISTERED ANp/OR ALTER.REPSPOSAL SYSTEM //-r,i�ie
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVEE//DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE PE.M �(� / �x �,[`: /�/.�� SACKFILL SEPTIC TANKS ❑
OF PERMITTEE V // YR^"�
SEEP,PIT IBI ❑ CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK.
M.0.
CASH
L{Lo 5 3 9 2—� 0V 16 1 0 D 5.00-
1
DEPAIVrMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION L
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I AUILDING
DDRESS
FO7APPLICA7NTILL IN LOCALITYulLolu=, � n^ - �DDRESS NEAREST7 />� CROSS ST NO. SERIALNO. ' PERMINO.
LOCALITY2RssST. L_ � 4 1&21r or I 1 Z7 3 SS S
.��� RECEIVED BV RentlY far IneDeotion GATE ISS(U.�ED
OWNER / �'e�/ 7—
MAIL
ADDRESSUSE ZONE OCCUPANCY MAP
n BK PG
CITY 1.,<cTEL.NO. /, 44 J
CONT CO.IMP.N0. Z
14
ADDRESS 106 NO.
CITY P TEL.N O. ❑ TRUNK PERMIT NO.
/ /�
REGISTRAT^N NO. QQ I, 6 8 COUNTY ROAD PERMIT NO. (/ LAE'��7
LEGAL
DESCRIPTION LOT NO////�V/�� '�/ .( Z STATE ENCROACHMEN.T�
// ^� PERMIT N0.
BLOCK TRACT (/A INDUSTRIAL
WASTE APPROVAL
I NO.BF BLDGS.
512E OF LOT
J�� NOW ON LOT c CHARGES
USE OF / /-
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE /
HOUSE SEWER CONNECTING TO _` REIMBURSEMENT FEE
HOUSE SEWER $ 3.50 o RECEIPT NO. DATE------
PRIVATE
IBV
HOUSES DISPOSAL
ECTING TO �
PRIVATE DISPOSAL SYSTEM I.00
CONNECT ADDITIONAL BLDG.OR / EXCEPTION RECORDED \
WORK TO HOUSE SEWER1.00
E
ALTER OR ISPIR.A ALXISSYSTEM
STETI E / DATE IBV
DISPOSAL
SEWER OR M I.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR /I
PITS AND/OR DRAINFIELD 2.00 STATION 2� ./. 7 Jr 5 DEPTH a
CESSPOOL—BRYWELL
SPECIAL CONDITIONS ONLY 2.00 ��--{{;; 3 MANHOLE REFERENCE
,7- �.9Od UPPER LOWER--
TYPE OF
OWER__TYPE.OF CONNECTION/ LENGTH FROM .��/
OWNERS PERMIT S I 00 V. CURB V P,L. M.L.TO P.L.
AUTHORIZATION TOTAL FEE U
I HAVE THIS DATE CONTRACTED WITH THE HE IN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE P BLIC SEWER 9 r�
SIGNED THIS�._._--- OF._....1. .._......- NEW HOUSE SEWER
OWNER OR /���„�. - CON NECT ADDITIONAL
OWNERS AGENT.... ... / '2�r• BUILDING OR WORK
ADDRESS....._. __.__... . AND/OR GRAINFIELD EPTIC TANK,SEEP.PIT(S)
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL DRYWELL El
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER. REPAIR.SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RE DENTIAL PROPERTY. BACKFILL SEPTIC TANKS y 7
SEEP.PIT(S)0 CESSPOOLS '
.,)'.5
SIGNATURE
OF PERMITTEE.. . .L '✓L'........... �
76AC42D 663 1/03