HomeMy Public PortalAbout10137 GREEN ST_Sewer__ lo-Ba
t6AB4eAe4tD APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DtPARTbUNT OF COUNTY ENGU EER
BUILDING AND SAFETY DIVISION ■uILDINa O�
rOHlf A L81�- CormEn ADDRW
WII1IAl[ A IE1f881. 8np'4 of BinAhaQ
LOCALITY
NEAREST
FOR APPI.ICANT TO FILL IN `"°" lTCIAL .
DESCRI C:,:,
n NO. OWNER
MAIL
L...1 I CT ADDRESS !
NO. OF SLOGS. ,
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROPP MAP PROCESSED BY
BUILDINGS H ■K PG
CONTRACTOR4
ADDR �^ (�
16e CONNECTION DATA
UI
CI NOS_ / STATION DEPTH
An MANHOLE R[FIE [ U "
REGISTRATION NO. COUNTY L [R
NO. DESCRIPTION OF WORK FSE TYPE OF CONNON LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURL PA_ MA_TO P.L.
PUBLIC BEWER $15.00 P.C.NO. (1
SEPTIC TANK,S AOE P OR CO.IMO. NO. .105 NO. VY
PITS AND/OR DRA I N FIELD $10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD fT NO. 0
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL KMG.OR AFFIDAVIT •yt[S WO[R R ORD ■TR.NO. DATE
WORK TO HOUSE irw[R $1.00
OV[RFLQW S[[PAG[PIT,DRAINFI[LO a
EXTN.,CESSPOOL, L,MANHOLE 111 $15.00
A DO OU■ HWY.OR ST.WIDENING Z
BEIVER 1.00 V STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WAST[APPROVAL
4�1rN
�y���. CHAROU
E S PERMIT f Z 00
AUT 01=TION rorAL FEE �Q CONNECTIO HARGE FEE
'1 HAVE AT THISDATE A CONTR^CT WITH THE HEREIN NAMED CON. REIM BURS[MENT FE[
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC B[WER. A MOVAIS DATE INSPECTOR'S SIl0 ATURE
SIGNED THIS DAY OF }p_
OWNR OR NEW HOUSE SEWER
OWNERS AGENT- CONNECT ADDITIONAL
pUILDI NO OR WOI{K
ADDRESS SEPTIC TANK SEEP,PIT(S)
I HR[BYACKNOWLEDGE THAT I HAVE READH
THIS APPLICATION AND/OR DRAINFIELD
AND STAT[ THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL CQUNORDINANCES TY ODINANCS AHD BTATE LAWS R[GULATINO
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHR[BY CERTIFY THAT I AM PROPERLY REGIST[RI D AND/OR ALTER.REPAIR,SEW"OR
LIC ENS[D Al REQUIR BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT A THE LE AL NO INTEND TO DISCONNECT PLUG AND
REGION IN, THE AN CRIB[ R NTIAL 01-9117y. ABANDON HOUBE SEWER Q-L7
BIONATUR[ BACKPILL S[PIET TANKS ❑
OF PKIRMITTEE SEEP,PIT(S) LJ CLSPOOLS El
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
LAL� 5 2 7 2 OCT 2 6 1 0 n 5.00-
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