HomeMy Public PortalAbout10126 GREEN ST_Sewer__ APPLICATION FOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
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ADDREIIS
JOHN A. LAMBIE, CDUNYY ENGINEER
T CAE18ATT D. GRIFFIN, HU►'T Qr BUILDING LOCALITY
FOR APPLICANT T FILL IN aR err. .
LEGAL S DINER
DESCRIPTION LOT NO.
MAIL
BLOCK T4tACT ADDRES!
110.OF BLD". CITY TEL. NO.
SIZE OF LOT NOM-0N LOT
OF
BUIUSELDINGS
DI DISTRICT N0. C P YAP
BUILDINGS
BK pa
CONTRACTO , --
CO ON DAT&
ADDRESS
C TEL NO STATION DEPTH
11,OHOLE REFERENCE. _ _ UPPER
--�7-E L01/ER
REGISTRATION N0. Q ZT ❑ COU►ITY ..
NO. DESCRIPTION OF WORK FE>i
HOUSE SEWER CONNECTING'TO TVP[OF CO�NBCTION GiH FROM
PUBLIC SEM S,pO Y. CURB P.L. Y.L.TO P.L.
SEPTIC TANK,SEEPAGE PIT OR -
PITS AfID/ORD INFFELD 9.00
P. C.
i
SGM_CESSPOO 2.00 CO. IMP. N0. JOB N0.
i HOUSE SEWER CONNECTING TO
i PRIVATE DISPOSAL SYSTEM Q 1.00 TRUNK PERMIT NO. ROAD PERYI O.
I CONNECT ADDITIONAL BLDG.OR STATE ENCROACHNENT
WORK TO HOUSE SEVER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSK
INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ 1.00
•RETE APPROVAL
CHARGES
CONXEC'TION CHARGE FEE -
OWNI��S PID S 1 , 00 REIMBURSEMENT FEE
AUTHORIZATION Taro. Fm
1 HAVE AT THIS DATE A CONTRACT WITH THE HIEREIN HAYED COX-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWKL4IN4
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS SAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGEYT SEPTIC TANK,SEEP,PIT(3) .
ADDR"* AI%D/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THt1T I HAVE READ THIS APPLICATION CESSPOOL DRYWELL❑
•AND YIATE THAT THY ABOVE IB CORRECT AND AGREE TO COMPLY
NRH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS, SEWAGE DISPOSAL SYSTEM'
I HEREBY CERTIFY THAT I AY PROPERLT REGISTERED AIID/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND BTATH OF ABANDON HOUSE SEW D
CALIFORNIA OR THAT I AY THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACXFILL BE IC TANKS
SIGNATURE ❑
SEEP.PIT 2) CESSPOOLS❑
OF PERMITTEE
JOHN A. LAMBIE, CouNTY ENGINEER YALIDATIO ROBERT A.WOOD,CHIEF PL.BG. INSPECTOR
CiL ■.0.
M484309 SEPI 5l0 A 4.00