HomeMy Public PortalAbout10813 GRAND AVE_Sewer__ 10-0>,
7eAe45AC4tD APPLICATION FOR. PERMI
COUNTY OF LOS ANGELES SEWER-S5-WAGE DISPOSAL
DtPAETMENT OF COUNTY ENGINM
B=ING AND SAFETY DIVISION
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A. TEMEN, Supl Of bid1cf1mg LOCALffY C
NEAREST 1
FO$ APPLICANT TO.FILL IN 74 CROSS ST. -
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LKOAL
DESCRIPTION LOT NO. OWNER
MAIL
SLOG TRA C'f 7 ADORES j
SIZE OF LOT 0 NOW OON LOTS / CITY �C/ D TEL. v–
US[ OF DISTRICT NO. OR MAP f•R SY
BUILDINGS
/� BK PO
CONTRACTOR tl`M /� ./ xT
CL
ADDR— ll co ON DATA
PITY TEL. NO. Q ! STATION DEPTH
STATE U PP[R'
R[OISTRATION NO. COU MANHOLE REFERENCE LOW"
NO. DESCRIPTION OF WORK FE[ TYPE OF cONNkcTION LENGTH FROM
HOUSE BEIVER CONNECTING TO Y. CURE F.L Y.L.TO P.L. }
FVBLIC SEWER a $8.00 P.C.NO. O••
i EPTIC TANK. EEPAGE F OR CO,IMF.NO. JOS NO.
FITS AND/OR DRAINFI ELD 0 $10.00 V
HOUSE SEWER C014MKCT'NG TO TRUNK PERMIT NO. ROAD PERMIT NO. Q[
PRIVATE DISPOSAL SYSTEM O $1.00 O
CONN CT ADDITIONAL BLDG.OR AFFIDAVIT rut[■ w[R[n RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER 0 $2.00
OVERFLOW SEEPAGE PIT,DRAINFIELO
E%T N.,Cw POOL,DRYWELLMANHOLE 0 S5.00
ASA D HOU■ V`/
HY. OR ST.WIDENING N
ISPOEAL... 7.00 STATE ENCROACHMENT
FERMIT NO.
INDUSTRIAL
WAST[APPROVAL
cHARoss
OWNERS PEMI�UT i 2 00
AUTHOMATION TOTAL FEE CONNECTION CHARD[F[[
'I HAVE AT THISDATE A CONTRACT WITH THE H[R[IN NAMKP CON- REIMBURSEMENT FE[
TRACTOR TO CO NN[CT THE (ISOVE DESCRIBED LX 1;10 DWELLING
TO THE PUBLIC SEWER. AMOVAM DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF
OWNER Oft NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRE/S BUILDING OR WORK
SEPTIC TANK.SEEP.PIT(S)
1 H[11EBY ACKNOWLtDO[ THAT 1 HAVE R[AD THIS APPLICATION AND/OR DRAI NFIELD
AND STAT[ TWAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTYORDINANC[B AND STATIK LAWS REGULATING
PLUMBING AND SEW EFM. CESSPOOL ❑ DRYW[LL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR '
LIC[N/[D AS R[OUIRED BY LOS ANGLES COUNTY AND STAT[ OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OW N[R OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, TWE A�S.O�VF DESCRIBED RESIDENTIAL SIDNTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE U BACKFILL SEPTIC TANKS El _
OF PERMITTEE BEEF.PTT(S) u CESSPOOLS
VAMATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CICS M.O. CASH
1563 JUL 18 1 0 D 500- 4
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�CESOI BAe4zD D APPLICATION FOR PERMIT
COUNTT OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DbAST UM OF COUNTY EN(}INEILR
B=INO AND SAFETY DIVISION BUILDING
voff1JOHN JL iMRM Ca= En SSi ADDRESS /�/
N T LLAX A. ter. Sup't of Bundling
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS `T.
L"AL7
DESCRIPTION LOT NO. `� OWNER e C
MAIL
BLOCKTRACT -3 3 V ADDREdA
NO. OF SLDG■. J
SIZE OF LOT NOW ON LOT ` CITY TEL NO.
US[ OF DISTRICT HO, hROUP MAJ PROCESSED■Y
■u ILDING■ ■K PG
CONTRACTOR N
ADDRESS
CO"ECTION DATA
CITY y TIL. NO
V STATION DEPTH
B STAT[ f UFT[R
REGISTRATION NO, COUNTY MANHOLE R[FETKNC[ 5
HO. DESCRIPTION OF WORK FEB TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO CURB P.L. M.L TO P.L
PUBLIC SEWKIt 49 55.00
FTIC A ,S[ AQE PIT OR CO.IMF. NO. JOS NO. H
FITS AND/OR DRAINFI[LD 510.00
HOUSE NEWER CONNECTING TO tRUNK PERMIT NO. ROAD PERMIT NO. O
PRIVATE DIBPOSAL SYSTEM 55.DO
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I •AIln I wtSrET RECORD.INS".NO. DATE O
WORK TO HOUSE SEWER 51.00
OVERFLOW SE[FAGB FIT,DRAINFIELD
EXTH.,CSSSPOO L.DRYWELL.MANHOLE 41 55.00 HWY.OR ST.WIDENING N
AL R AIR O ASA Ouslit
SEW[R OR DI/POSAL SYSTEM 3.00 STAT[QICROACHM[NT Z
PERMIT NO.
INDUSTRIAL
WAST[APPROVAL
CHARGE/
OWNER'S PERMIT IS z 00
A=ORII.ATION TOTAL FEE 1 CCHARD[F[[
V RIIMBU IMBURION RS[w C1lt'FtE
'I HAVE AT THIS DATE A CONTRACT WITH THE H[R[IN NAMED CON-
TRACTOR TO CONNECTE THE ASOVDESCRIS[D KXISTINY SIGNATURE
Q DWELLING If T1T1fl OVL11a7
TO THE PUBLIC SEWER. AMDAT[ I [CTOR
SIGNED THIS DAY OF 1G_
OWNER OR MEW HOUSE S[WKA S�
OWNERS AGENT CONNECT ADDITIONAL
PUILDING Oh WpRK
ADDRESS SEPTIC TANK.SEEP.PIT(S)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS P
APPLICATION AND/OR DRAINFIELD
AND STAT[ THAT THE A50VE IS CORRECT AND AGR[[ TO COMLY
WITH ALL COUNTY ORE
DINANCS AND STATE LAWS REGULATING
PLUM SING AND SEWBR0. CESSPQOL ❑ DRYWELL ❑
1HERESY CERTIFY THAT I PROPERLY IST[RED AHD/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRED BY ANGLES C U AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM LEGAL OW R AND IHTEND TO DI SCONN[CT PLUG AND
RESIDE IN, THE ASOVE ISLD RESID T ROP[RTY. ABANDON HOUSE SEWER
SIGNATURE 6ACK FI LL S[P�IC TANKS ❑
OF FERMITTQ •6 V.PIT(S) B CWPOOIJ!
ALIDA'I'ION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGFNEER
CK. M.O. CASH
L 9 1 2 0`2 w 3 1 0 D 7,00~ v