HomeMy Public PortalAbout5624 GRACEWOOD AVE_Sewer__ S&E-6 311.55 APPLICATION FOR PERMIT ,`,- ,�2_ V-,2-
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Depwtment of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS t• �;L'`l
T) CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS ST. {
LEGAL OWNER
DESCRIPTION LOT NO.
MAIL
BLOCK TRAC ADDRESS
0.OF BLDGS.
SIZE OF LOT ' NOW ON LOT CITY TEL. N0.
USE OF _j
DISTRICT NO. GROUP MAP
BUILDINGS PG
i
CONTRACTOR
CONNECTION DATA
ADDRESS qq 7
CITY EL. NO. 11Ll j�� STATION �' 1° DEPTH
MANHOLE REFERENCE r _741 IL PP
LER
012(1 ElCOU TY 4�
REGISTRATION NO
NO, DESCRIPTION OF WORK FEE
TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @
HOUSE SEWER CONNECTING TO Y. CURB, L. M.L.TO P.L.
SEPTIC TANK,SEEPAGE PIT OR ®
PITS AND/OR DRAINFIELD @ $3.00 ���V••//
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. NO.
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. NO. JOB NO.
I HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 _TRUNK PERMIT NO. ROAD PERMIT NO
CONNECT ADDITIONAL BLDG.OR `/" STATE ENCROACH NT
�L WORK TO HOUSE SEWER @ $1.00 PERMIT N0.
ALTER,REPAIR'OR ABANDON HOUSE' INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVA
CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT g
REIMBURSEMENT FEE
AUTHORIZATION I TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK t 'd
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD -
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
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 REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEW D
CALIFORNIA OR THAT 1 AM T E LEGAL OWNER OF THE ABOVE -
ER
DESCRIBED RESIDEN L OPE BACKFILL
AC FIL (SEP❑ CESSPOOLS[IS❑
SIGNATURE __SEE----
OF PERMITTEE '
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. N.0. CASH