HomeMy Public PortalAbout5632 GRACEWOOD AVE_Sewer__ A842D
CE808 8.89 APPLICATION FOR PERMIT
CE7
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING s
-
JOHN A. LPINIBIE, County Engineer ADDRESS ,
CASSATT D. GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL / - /
DESCRIPTION LOT NO. G a, - OWNER
BLOCK
BLOCK TRACT MAIL
ADDRESS
' NO.OF BLDGS.
SIZE OF LOT` �" NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS = - DISTRICT N0. GROUP I BK PG MAP PROCESSED BY
I
CONTRACTOR
ADDRESS a(+ CO NECI DATA vrG..
CITY _ TEL.N0. STATION DEPTH 7.
❑❑ STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. ❑ COUNTY r
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Co) $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO. -
INDUSTRIAL
_WASTE APPROVAL
CHARGES
OWNERS PERMT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE e REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONeECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
` SIGNEDJAGEN
DAY OF 19_ NEW HOUSE SEWER
OWNER O - - CONNECT ADDITIONAL
OWNERS BUILDING OR WORK
SEPTIC TANK,SEEP.PITS)
ADDRESS - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATI N
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
L
COUNTY ORDINANCES AND STATE LAWS REGULATINGALTER,REPAIR,SEWER OR
AND SEWERS. SEWAGE DISPOSAL SYSTEM
Y CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
IA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE RESIDENTIAL PROPERTY, BACKFILL SEP❑C TANKSCESSPO0LS ❑E - - SEEPPITITTEF /
OF VALIDATION ROBERT A. WOOD
r-�' M.o. CASH SUPERVISING MECHANICAL ENGINEER
i
C
DF.PAxM[Eivm OF OOUNTY ENGI 3MM SEWER�SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF L08 AWGIU.1d�
WILLIAM J. FOX. C'ouwTY EN0IH6[R BUILDING f
ADDRESS
FOR APPUWT TO RLL IN LODAUTY C
BUILDING � 1 NtOSS8T /
ADDRESS +,7 L �,h�y- S��-,1p�•{} ) OROi88T.
LOOAUTY � � —� DISTRICT NO. SERIAL NO. PERMIT Y0.
NEAREST - p� n 1 l4 RE WE BY Rumor fw Ippwu*n DATi�
CROSS ST. ED
! 7 '{
OWNER Sr
MAIL
ADDRESS USE ZOGE OOOUPAYQY MAP
BK PR
CITY TELNO. A-1
COKTRAOTOR . V
CO.[NP.N0.
ADDRESS �
JOB NO.
CITY �j h _ TELNO. +� &�(� C� 2 TRUNK PERMIT NO.
[]
REGISTRATION N0. LJ STATECOUNTY ROAD PERMIT N0.
LEGAL
DESOSTATE ENCROACHMENT
BIPTIOY LOT N0.
PERMIT NO.
BLOCK TRACT INDUSTRIAL
SIZE OF LOT N0.SF BLDGS. WASTE APPROVAL
NOW ON LOT CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OIr WORK FEE
HOUW SEWER OONNEOMN TO REIMBURSEMENT FEE
PUBUD SEWER 40 1 >L6E RECEIPTYO. DATE BY
-HOUSE SFWEN 0ONNEcMNQ To
�•f PRIVASPOSAL SYSTEM I.M �G
CONNECT hLb4L
WORK TO HOUSE ADDITIONAL
SEWR R
Ti1.01
EXCEPTION RECORDED
)ik--qR—lEPKTK1XI N NC- DATE BY
SEWER OR DISPOSAL SYSTEM I.M
DISGONNE&AND ABANDON SEW"
AND/OR DISPOSAL SYSTEM I.1/ CONNECTION DATA
ANK. DR
PITS ANDOR DRAINFIELD 2-M STATION DEPTH
SPECIAL OONOITIONS ONLY 201 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTIONLENGTH FROM
OWNERS 6RMIT $ 1 00 Y. CURB P.L. M.L.TO PA-
AUTHORIZATION I TOTAL PI=E D
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
OONTRACTOR TO DONNEOT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR' GNATUBE DATE
DWELLING TO THE PUBLIO SEWER
SIGNED THIS CAY OF 19_ NEW HOUSE SEWER '
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS
SEPTIC TARK.SEEP.PIT(S)
ANDOR DRA NFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPU- CESSPOOL E] DRYWELL E]QATION AND STATE THAT THE ABOVE 16 CORRECT AND AGREE
TO DOYPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS. 8EWAGE DISPOhAL SYSTEM
1 HEREBY CERTIFY THAT 1 AN PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CAUFORNIA OR THAT I AN THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BAO F LL SEPTIC TAM ❑
SIGNATURE ( SEEP.PIT(S)E] CESSPOOLEE]
OF PERMITTER ' n ` �� +`
MARID 60 1/63