HomeMy Public PortalAbout5527 GRACEWOOD AVE_Sewer__ `EBDB 'E-°°
TaA 6421L APPLICATION FOR PERMS ��JJ1II��II
COUNTY OF LOS ANGELS SEWER-SEWAGE DISPOSAL
DIErARTMKNT OF COUNTYNOIN
E [[R
■UILDING AND SAFETY DIiLVISION ■uILDING
JOHN A. LAMSI[. CouNrY ENaIN[[R ADORES
COLEMAN W. JEENKINS. SUPT. OF BUILDING
LOCALITY
NEAREST
FOR APPLICANT TO FELL IN IcLIECIAL
RDSB Sr-
DE/CRIPTION LOT M(S. OWNER
MAIL
BLOC - ADDRESS
No. OF ■EOGs.
■IZE OF LOT MOW ON LOT CI TZL No.
US[ OF
■UILDINGS DISTRICT M GROUP MAF PROCIISED SV
CONTRACTOR
�� d�' - ro
ADDRESS CQ CTlQlf AZA
CITY d TEL. NO. /
.� -Aq(Z
STATION DEPTH
ATE
UPPER
`ICENSE NO,vZ / CILAfs l.:_-.- MASH OL[REFERENCE
NO. DESCRIPTION OF WORK FEE rYPf of CoNMECTIoH LENGTH
HOUSES R C M[CTIMQ TO Y. CUR■ P.L M.L.TO P.L
PU■LIC fIW 50,pO
IC TANK, GE RI P.C.NO.
PITS AND/OR D!{AINFI[LD 510.00
CO.IMP.NO. _ JO■NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT MO.
PRIVATE DISPOSAL SYSTEM ` 53.00
-CONNECT ADDITIONAL SLUG.6R
WORK TO HOUSE BEW-EA 51.00 AFFIDAVIT I SArY[■ [AfiR[R RECORD.IM/TR.NO. DATE
U
OVERFLOW 800PAGE PIT.DRAIMFI[LD D=
[7[TN..CESSPOOL,DRYWELLMANHOLE 41 $0.00 O
A BANDHouat HWY-OR ST.WIDENING ^ t
■[W[R SYSTiM S3.00 STATE ENCROACHMENT d
PERMIT No. r Crj
INDUSTRIAL
��
�t�n• WAST[APPROVAL7 OWNS �IS �Q'( , 2 0 HARD
A V HOFXK4 ON =Q=A1 FU 0-0 CONNECTION CHARGE Fti
I HAVE AT THIS DATE A CORTRACT WITH THE H[R[IN MAL[D CdM- RE IMBURSFMEHT FEE
TRACTOR TO COMNECT THE ABOVE DESCRIBED QSISTIN, DWELLING
TO THE PUBLIC SEW OvAiz DATE INIfPKCTOR'S SIGNATURE
SIGNED THIS DAY OF
OWNER OR NEW HOUSE SEWER
OWM[RS AGE
CONNECT ADDRTIOMAL
ADORES
aUILDING OR WORK
SEPTIC TANK.SEEP,PIT(lb)
I H[REMY ACKNOWL[DG[ THAT J HAVE READ THIS APPLICATION
AND STATE THAT TH[ AaOV� IS COR R[CT AND AGRQ TO COMPLY AND/QR bRAIMFIELD
WITH ALL 00 NTV 0RDINAMC[s AND STATE LAWS REGULATING
PLUM BIND AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CFRTIFY THAT I AM PROPS ELY REGI ST[RED AND/OR ALTER,REPAIR,SEWER OR
LIC[110ED As REQUIRED BY LOS ANGLES COUNTY AND STATE OF S[WAgR DISPOSAL SYSTEM
GLI FOIFMIA OR THAT I E LEGAL OWNER OF, AND INTEND YO DIsCQN N[CT PLUG AND
Zz
RESIDE IN, THE
Ap0 D IB<D RESIDENT PRQm RTY. ASANDOM HOUS[°[W[R ry / O
SIGNATURE BACKFILL BEFfIC TANKS LI
OF P[F(wTT`(iI S[[P.PIT(s) ❑ CESSPOOLs
VALIDATION JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
A 9'9t2 Pff1 1 0 D 5R001
APPLICATIOWFOR PERMIT
DIY=ON OF BU=WQ AND SAFETY SEWEREWAGE DISPOSAL
D"arhmat of qtr Eayfaws
Co" of Los AIIwomm BUILDING
W#1.J. ICOUNTY. COUNTY=NotNKWt ADDRESS
CAS1sATr b.CiPU 1N,S UP-T of Wun.°ut. LOCALITY I
FOR APPLICAM TO FILL IN REAREST {/ CAR
LEGAL
DESCRIPTION J-OT R0. / 07XEII7, Ric
BLOCK TRACTs p'L D ,3 iG MAIL
SE
A HE
NO. OF BL.DGS. 9 -
flZk OF LOT X07 ON LOT /`- CITY TEL. NO.
USE qqF /
BUiL.DINGS / DISTRICT N0. GROUP MAP
B[ PG
CONTRACTOR
ADDRESS CONIC=01f DJLTA
CITY'• /, TEL No. � 70 7 STATION V I O DEPTH
E7 STATIE XANHOLE REFERENCE
REGISTRATION NO. a BOUNTY
r
NO. DESCRIPTION OF WORK FEElie
OF ECTI LEN GTHOM
HOUSE SEWER CONNECTING TO 0 .L. Y.L. TO . Cl
PUBLIC SEWER 3.50
gU3EAVER CONNE IMG TO
PRIVATE bI8PO'AL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR P. C. N0.
WORK TO HOUSE-SEWER 1.00 CO, IMP h0. JOB NO.
I ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK P YlT NO. ROAD PERMIT N
RISC HXECT AND ABANDO SERER STATE EXCR
AHDPORTID�IBPOdAL SYSTEM 1.00 PERMIT NO.
I SE a AND/OR,SEEPAGE DRAIINFIELDPIT OR 2.0-0
INDUSTRIAL
- GGFF��I1POOL-pp YW Lr- VfASTK APPROVAL
91E IAL COM�IT t�MB ONLY 2.00 CHARG69 I
Off'$ 1 $ 1 00 CONNECTION C E FEE
AUTSOBMTION TOTAL FEE REIN EMERY FEE
I 41AVE TH15 DATE CO CTED WITH T E HEREIN MA ED COX- f1�7]
TRACYOR TO CONNECT THE ABOVE DESCRII�ED EXISTING PNFLI-INC APPROVALS DATE INSP[CTO!'S rIGNATURS
TO THE PUBLIC 1 EW NEW HOUSE SEWER
SIGNED THISDAY OF � 19sZL
OWNER BUILDING OR /`I�� �� COHNEO"r WORK OR 0RK
AL
hD 17
W
OWNERS AGEX7
6EPTIC TANK,BEEP,PIT(5)
ADDRESS AND/OR DRAIXFIELD
1 HEREBY ACKNOWLEDGE THAT 1 RAVE READTHI'}'} APPLICATION CESSPOOL❑ DRY7-ELL ElANiD}1STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
PLUMB L AND d� ORDINANCES A*D STATE LAWS REGULATING ALTER,REPAIR,9 ER OR -
I HEMY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SE11 Gk DIBPOSAC SY�TEY
LICENSED AS R[QUIRED BY LOS AIIG" COUNTY AND STATE OF D 'ON
PLUG AND
CAUFO NIA OR THAT I Ali THH GAL OWNER OF THE ABOVE A'3AXDON H 0 U 5 E 3Elf ER
DESCRIBED REdIDXKTIAL PROPERTY. BAC�F(LLS C TAX[3 l:
SEEP. PIT 5 CE9bP00LS
SIGNATURE
OF PERMITTEE
WILLIAM J.FOX,COUNTY EiO1NEim VAY.IDA71ON P_A.WOOD.Cr11wr PLsa. IN�rtCTOR
v j 48,97D,. EFS 7 4 5.50 '�