HomeMy Public PortalAbout10119 GREEN ST_Sewer__ 7EA 542D - CE808 - 9/79 APPLICATION FOR PERMIT
COUNTY of LoS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADD,—
LOCALITT
FOR APPLI 7 0 FILL IN N !+
s*'
LROAL
DESCRIPTION LOT Nb./Y7 ++�� OW N[R
[LOCK TRACTS •� of ' MAIL
ADORN
N O. OF "I".
SIZ4 OF LOT NOW N LO, CITY TIL NO,
USE OF VTRICT r0. S OUP AF y ROC QED ■Y
EUILDI Ned
- BE PS
QO14TRACTO'R { ��.O -S 133
ADORN[ - � i ox DAT
/�
CITY ru.. NO. ']ITAT7aN. J.�— DZF" /Q/
STATEII�� LIC YAxt�oL12 n[Ft1tE NC'[ �
LIC"It NO, p( CLA7S AIALCWXR
NO. MscmirrioN OR WORK mill TYPE OF CONNECTION Lklia7H FROM
HOUSE• ER CONN4=NG TO Y. .C.UR■ Pa- Y.L Tb P.L
PUSLIC/[W b1 0 $7.00 F.G.NO.
IC P Of F Oft �.IY JO■NO.
PITS L
Atfp/OR DRAINFIED 910.00
Houst SEWER CONNECTING TO TRUNK PERMIT NO. RbAD r[]IMTT NO.
PRIVATE DISPOSAL SYSTEM' 92.00
CONNECT ADDITIONAL SLDO.OR AFFIDAVIT I VAREE IAAMCM RECORD.INSTR.NO. DATE
WORK TO HOU[[SEWER 97-00
R
OVEFLOW■@ R
AGE PIT.DAI?IFI[LD
[RTN..CE1 DRYWELL 98.00
ALTIOR.REPAIR OR A HWY.OR ST.WIDENING
E
SWER R ORD SYSTEM 3.00 STATE[NCROACHMKWr (--
MANHOLE $7.00 PERMIT NO.
INDUSTRIAL
WASTKAPPROVAL
OWNWS P£EIQr s o- GHARG"
AUTHORIZATION ToTAy pgg / CONNECTION CHARGE ru
I HAV[ AT TRI■ DATE A CONTRACT WITH THE H[R[IN NAMED CON- REIMSURS[MENT FE[
'TRACTOR TO CONNECT THE ArOVE DESCRISED EEISTING DW[LL INC m ■a
TO TH 9I FU[L1C SEWER. APPROVAIS DATE INfPECTO ' IGNATURI
SIGNED THIO {:TAY OF 10_
OWNER OR NEW HOU/k SEWk_R _
OWNER(AGENT CONNECT ADDITIONAL
SU ILDI NO OR WORK
ADD REIT SEFTIC TANK.SLIP.PIT(S) _
1 HERESY ACKNgWLEDGE THAT I NAVE READ THIS APPLICATION AND/OR DRAINFI[LD -
AND STAT[ THAT THE ABOVE 19 CORRECT AND AGR[[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CEiSPOOL ❑ DRYW[LL [IPLUMSING AND SEWERS.
I HERE h' CERTIFV THAT I AM "OPEkLY REGISTERED AND/OR ALTYR.REPAIR.SEWER VR
LICENSED AS REQUIREAA
D BY LOS NGLYS COUNTY AND STATE OF SEWAGE DISPOSIAL SYSTEM
CALIFORNIA OR THAT M THE LEG 'SER OF. AND INTEND TO DIfCON rL.UO AMD
RdID9 IN. THE A D[SCRLS Ip[NTIFR/QPLRTY A ON-HOUSE SEWER
SIGNATURE ` .
OF P9i YTTTEI ' t w SACT((FILL C NKl ❑ i��7
r� ) LIE O'/
V ATION CR: M.0. CASH
4 2 BrFEB 10 9