HomeMy Public PortalAbout10111 GREEN ST_Sewer__ �; `�' APPLICATION FOR PERMIT,.,
SEWER - SEWAPE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN MSTMIcT NO. anqur PROCES&D n
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I HERESY'ACKNOWLEDO9 THAT'I HAVE READ THIP APPLICATION • _ - _ _. -
Atm.(TATE THAT THE ABOVE LS CORRECT AND AORSE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS RSGULATINO
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76A 642D -CE808- 10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRES9 1.011.1. E. Green at.
LOCALITY Temple City
FOR APPLICANT TO FILL IN NEAREST CROSS ST. Baldwin Ave.
LEGAL Michael Palmiter
DESCRIPTION LOT NO. ? OWNER
MAIL
BLOCK TRACT ��+ G7"" ADDRESS 1.011.1 E. Green St
f ,+NO. OF BLDGS. City �.1.I.2-2 `�1
SIZE OF LOT ZZ'S_NOW ON LOT CITYTe::1 l e C i y TEL. NO.
USE OF U
BUILDINGS Iles �� DISTRICT NO. GROUP BK MAP Po SSED BY
CONTRACTORS uare Deal Sewer Service 6� ,fes-
ADDRESS 2933 Maxson Ad. C//ONNECTION DATA
CITY
E1 Monte TEL. NO. -2020 STATION DEPTH
STATE18Ci
_ C O O LIC c— 2 MANHOLE REFERENCE '3��- j� ! I� LOWER
LICENSE NO. 1
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FIR M Q
1 HOUSE SEWER CONNECTING TO L'] Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER $7.00
P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR /Bj,..Mef.F�
O.IM NO. JOB NO.
PITS AND/OR DRAINFIELD @ E10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. d
PRIVATE DISPOSAL SYSTEM @ $3.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASE M17 ECORD.INSTR.NO. DATE U
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL. @ E5.00 O
ALTER,REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 _ STATE ENCROACHMENT W
MANHOLE $7.00 PERMIT NO. d
—
INDUSTRIAL WZ
WASTE APPROVAL
CHARGES
OWNERS PERMIT E
AUTHORIZATION TOTAL FEE
CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THISAY O UC7.(.1'YI 19_ i•
OWNER ORPOT NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL ROPERTY. ABANDON HOUSE SEWER
SIGNATURE ✓ El
OF PERMITTEE
SIGSEPTIC TANKS
SEEP.PIT(S) SSP OLS ❑
VALIDATION CK. M.O. CASH