HomeMy Public PortalAbout5625-31 GRACEWOOD AVE_Sewer__ 7aA6429—cEe04y-1071 APPLICATI N FOR P MIT
COUNTY OF LOB ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 1
ADDRESS
LOCAL I
NCAR[ST
FOR APPLICANT TO FILL IN I ,::..
DESCRIFTION LOT NO. 7._ OWNER
MAIL
BLOCK TRACT L/_ ADDRESS
NO. OF BLDG . h
SIZE OF LOT NOW ON LOT CITY TIL NO. _.i
USE OF DISTRICT X0. /ROUP MAP C[/SED BY
■U ILDI NOS
Pill
CO NTIUCTOR
R
// � L
ADDRESS ,'�, [v CONNECTION DATA
CITYE_ I TEL. NO. STATION OL5,•p DEPTH
STATE LIC MANHOLE REFERENCE UPPEIS
LICENSE NO. CLASS 3 2,-7 a�o�
NO. .DESCRIPTION OF WORK FEE T`/P[OF CONN[CTIo LENGTH rRoM� Q
HOUSE S[WFR CONNECTI NO TO Y. CURD P.L M.L.TO P.L.
PUBLIC SEW" O $7.00
NO.
SEPTIC TANK.S[ PAD[PIT OR F.C.
F 1T1!AND/ORRAIN FI ELD $10.00 CO.IMP.NO.DJOB NO.
HOUSE SEW[R CON N[CTIHO TO TRUNK PERMIT NO. ROAD PERMrr NO. d
PRIVATE DISPOSAL SYSTIM /7.00 O
CONNECT ADDITIONAL BLD O.OR AFFIDAVIT fuR■ -w[R[RT RECORD.INSTR.NO. DAT[ V
WORK TO HOUSE/EWER $2.00
OVERFLOW/[[PAGE PIT.DRAINFIELD OC
[XTN..C[DSPOOL.DRYW[LL SE.00 O
At IR OR ABANDON O �J HWY.OR ST.WIDENING
SEWER OR4a1SALQ&" &YSTIM /E.00 `r STATE ENCROACHMENT
MANHOLE ! $7.00 PERMIT NO.
INDURTRIAL
WAST[APPROVAL Z
OWNER'S s a 00 CHARGES
l,LII CONNECTION CHARD[FI[
AUMORMATION1 TOTiu. FEE
1HAVE AT THIS DAT11 A CONTRACT WITH THE HER NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIMILID [AI/TINO DW ELL Lu
TO THE FUEL IC S R. APPROVALS DAT[ INSPECTOR'/510HATURK
SIGNED THIS_ Y OF 1G�
OWNER OR NEW HOUSE SEWER
OWNERS AOENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP.PIT(S)
I E
HR[EY ACKNOWLEDGE THAT I HAVE READ THIS A LIGATION AND/OR DRAINFIELD
AND STAT[ THAT THE ASgVE IS CORRECT AND AOR[[ TO COM FLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUM,ALL
AND SI W[RS. CESSPOOL ❑ DRYW[LL ❑
IHERESY CERTIFY THAT I AM PROPERLY REGISTERED AHD/OR ALTER.REPAIR,SEWER OR
LICENSED AS REOUIR[D BY LOS ANGLES CO TY NO STAT[ OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM T LJ[G�LON F, D INTEND TO DISCONNECT PLUG AND
REST D[ IN. THE ANOV [DI L P Pr,IRTY. ARAN DON HOUSE■EWER (�
SIGNATURE ❑
OF PERMTTT[I SACKFILL S[ G TANKS
S[[P.PIT(a) =POOLE
VAL72 ;_
11�1 :) N.O. CASH
Z
i �'- 1 J1R 17 1 0 D 6,0 01 a
DEPAICTAfENT OF OOUN= ENGINE SEER--SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATI
OOUN= OF 1,08 AN(�EI.E9 r
WILLIAM J. FOX, COUNTY ENOIN[ER ADORE 2J 25 --.Z7—Z 7'.
FOR APPLICANT TO LL INBUILDING
ADDRE88 ✓— r
LOCALITY BIRTH CT M0. SERIAL M0. PERMIT M0.
NEAREST A 7 S
CRO Ga ST.
REC IV B Rum for IupoatJo■ DAT 8SU D
OWNER
ADDRES8 / ,& e-,M AIL USE ZON OCCUPANCY Y P
BK PG
CI ML-NO.
COIfTRAOTOR /2 { Co.IMP.M0. -
ADDRESS
JOB NO.
CITY TRUIIK PERMIT N0.
STATE
REGISTRATION N0. tr Hp'COUNTY ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO. PERMIT NO.
BLOCK TRACT Q INDUSTRIAL
WASTE APPROVAL
SIZE OF LOTN0.OF BLDGS CHARD
NOW ON LOTJA
USE OF CONNECTION CHARGE F
BUILDINGS
NO. DESCRIPTION OF WORK FEE
1 HOUR SEWER DONNEOTING TO REIMBURSEMENT FEE
PUBLIO SEWER { IL" BHOEIPT N0. OATH BY
H S N ING TO
PRIVATE DISPOSAL SYSTEM Im
WORK TO HOUSE SEWER LDS_08 1.08 OEPTIO ECORDHD
ALTER OR REP D T[ I BY
SEWER OR DISPOSAL SYSTEM IAO
DiscowliEdTAND ABANDON SEWER
AMD OR DISPOSAL SYSTEM- 1.90 CONNECTION DATA
SEPT TAN . PAGE PIT 08 p
PITS AND OR DRAINFIELD Loo STATION �O i Q DEPTH
OESSPO L--0RYWELL
SPEDIAL DONDITIONS ONLY 2-00 ERENOHa MIKPJZ
TYPE OF CONNECTIO LENGTHP LOMO
OWNERS PERMIT s oo `J
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
OOHTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIAY n;: 19 `�'• NEW HOUSE SEWER 1-�O
OWNER OR L t,^ {' OONNEOT ADDITIONAL
OWNEps AGENT -� r BUILDING OR WORK
ADDRESS SEPTIC TARAI SEEP.PIT(8)
AND OR DRA NFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL E] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO DOMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIF%SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPO AL SYSTEM
I HEREBY CERTIFY THAT I AN PROPERLY REGISTERED
AMD/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISDONNEOT PLUG AND
AND STATE OF CALIFORNIA OR THA. ■ THPLEGAL OWwf ABANDON HOUSE SEWER
ER OF THE ABOVE D RIBED NTIAL ROPERTY/ 6 IC TANKS r-1
CS8
0` Sfi[P.PIT(S)
SIGNATURE
OF PERMITTE
`Gl94tA 6Q3 T/f3