HomeMy Public PortalAbout10150 GREEN ST_Sewer__ CFEOEA642L A 4/72
7 Q APPLICATION FOR ERMIT
COUNTY OF LOS ANGELES SEWER-SEW DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ■UILDINa D
APDR[SS
LOCALITY
HEAR
LST
FOR APPLICANT TO FILL IN CROSS RT.
LEOAL
DESCRIPTION LOT NO. OWNER
/ MAIL
■LOCK TRACT — / Q ADDRUS
N" 0"
BLDGS.
SIZE OF JJOW ON LOT CITY TEL. NQ.
USE OF
Eu ILD WaI DISTRICT NO. •ROUE MAF C6SDED BY
■R PS
/l l
CONTRACTO D.y/(p S+ /`
ADDRLES d CONNECTION DATA
CITY 0 NO STATION /� DEPTH
tTATI / LIC r MANHOLE R[F[IT[NC[
LICEHO[ NO7 P7 6 riAas LOWER
No. I DESCRIPTION OF WORK r[[ TYRE OF co NN to L[ 0THFROM
HOUSE SEWER CONNECTING TO Y. C — M.L TO P.L_ 'U
PUBLIC SEWER V }
HK.SEEPAGE
ORTF.G.NO. O_
FITS AND/OR DRAINFI[LD f CO.IMP.NO. JOB HO. O
HOUSE
UR SEWER CONNECTING TO TRUNK PERMIT NO. ROAD I"M IT N V
PRIVATE DISPOSAL■Y STEM + Q Z 0
CONNECT ADDITIONAL GLDO.OR AFFIDAVIT EAT�LE WREST RECORD.INSTR.NO. DATE
WORK TO HOUR[SEWER O
OVERFLOW SEEPAGE PIT.DRAIN FIELD 1LJr,JI
R)CTN..C RL H
S S PO OL.DRYWILLMANOLE 4
H
AL R,AIEPAIIR OR ARANDO HO WY. OR ST.WIDENING � A a
SEWER OR DISPOSAL SYSTEM STATE ENCROACHMENT {Z!J
PERMIT NO. '
INDUSTRIAL
WAST[APPROVAL
CHARGES
O S PERDQT s D
CONNI<¢TION CHARGE FEE
AUTHORIZATION TOTAL FEE •CG d
1 HAVE AT THISDATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT PER
TRACTOR TO CONNECT THE ABOVE DESCRIBED ERISTINQ DWELLING TITDOV!}i�►7
TO THE FU■ f[
LIC SEWER. L PPR DAT[ INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF iD_
OWNER OR U
KEW HOSE SEWER
OW N[Rl Aa CONNECT ADDITIONAL
BUILDING ORWORK
ADD RLS
SEPTIC TANK.SEE},PIT(9)
1 H[R ACKNOW LIDO[ THAT I HA [ READ THIS APPLICATION AND/OR DRAINFIELD
AND ST THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS
REGULAT INO SPOOL ❑ DRYW[LL ❑
PLUM RENO AND SrW ERS.
I HEREBY CFRTIFR
Y THAT I AM PROPERLY REGISTERED AHD/OR ALTER.REPAIR.SEWER OR
f LICENSED AS R[OUIRE6 ■Y OS TS
ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I E LEGAL OWNER OF, AND INTEND TO DISCONNECT FLU O AND
RESIDE IN, THE AB0V RIBED RAID AL PROPERTY. ABANDON HOUSE SEWER
SIOF APERMiTTQ TURK BACKFILLS{ +� [
[I 2 cwroou
CATION
< ea�c /13SO. CASH
. Z.
4 . 010:- 131.0C3 �
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4/72
7BA84zL APPLICATION FOR PERMIT
�eAea
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPO
dtA
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ■UILDIN n
ADDRW
LOCAL"
NEAREST r
FOR APPLE T TO FILL IN lc". ,.
DESCRIFTIbN LOT No. OWNER
MAIL -- )
BLOCK TRACT V
NO. OF BLDGS.
■IZ[ OF LOT L. b NOW ON LOT CITY TCL NO.
U■[ OF fA.TH
O. OUP MAP OC ■SED BY
BUILDINGS SK PS
CONTRACTOR A0DREf■ � j CONNECTION DATA
CITY TCLNO. _eZ DEPTH
STATS LIC �j R[F[11tNC[ rLICENSE NO.. Ci_ASS(r. LOWER
No. DESCRI I N F ORK FC[ OF co [cT Nt[NG7H FROMHOUSE REWER CONNECTING TO M.L TO P.L.
PUBLIC SEWER
• PT AN SECPAO[PST OR PITS AND/OR DRAIHFI[L.D a O. /1HO ■ •EWER CONNECTING TO RMIT NO. ROAD PERMIT NO }8PRIVATE DISPOSAL SYST[idCONNECT ADDITIONAL■ .OR 9mrn wnirT RECORD.INSTR.NO. DAT[
WORK TO HOUSE SEWER
OVERFLOW•[[PAGE PIT.DRAINFIRLD
[)[TN..CEI■POOL_DRYWELL MANHOLE
A .REPAIR OR ASA N OUf HWY.OR ST.WIP[NING d
SEWER
OR DISPOSAL SYSTEMS
STAT[ENCROACHMENT Z
PERMIT MO.
12 dtNDUfTR AL
��. WAIT[APPROVAL
CHARGES
PERIIgT
AUTHOR ATION TOTAL FEF CONNKCTION CHARGE F[[
1 HAVE AT THIS DATE A CONTRACT WITH THE H[R[IN NAMED CON- R=IMBURSEMIE FIDE
I TRACTOR TO CONNECT THE ABOVE D[ICRIBKD L1[IBTING DWELL I NO
To THE PUBLIC •EWER. OVAIs DATE INfT[CTO R'S SIGNATU R[
SIGNED THIS DAY OF 10_
OWNER OR N[ USE f[W[R
OWNERS AGENT ONM[GT ADDITIONAL
BUILDING OR WORK
ADDRL■
I HEREB O [ -H I HA ROAD THIS APPLICATION AND/OREPTIC ANA.SCEP,PITIS)
AND STA AT T ANQVE I• CORRECT AND AOR[[ To COMPLY AHD/OR DRAINFI[LD
WITH COUNT ORDINANCES AND (TATE LAV" REGULATING
PLUM■ AND • [RS. CESSPOOL ❑ DRYW[LL ❑
1 H[R[S.Y CERTIFY THAT I AM PROPERLY REGISTERED AHD/OR ALTElI.REPAIR.SEW[R OR
LICENSED AE REQUIR Of ANGLU COUNTY AND STATS OF SEWAGE DISPOSAL SYSTEM
G L FF OR P41
OR THA [GAL OWNER OF. ANP INTEND TO DISCONNECT PLUG AND
RESIDE- THR A [D RUID[NTIAL PROPERTY. ABANDON HOU•[SEWER
SIGNATURE ❑
PERM BACKFILL SEPTI1C TANKS
OF
■[v.PIT u) LJ cwroou
ATION
CK. M.O. CAS
.� s9�m '2_0I.i o 30.0 0 A.
6&X-6D011-53
APPLICATION FOR PERMIT
40D=ON OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
County Of La. Angel" BUILDING /1 /ti /`
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS 40 V
m CAB-BATT D.GRIFFIN, Bur•T or CuILmmo LOCALITY
EV
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL �� OWNER
DESCRIPTION LOT N0.
PAIL
BLOCK TRACT .ADDRESS
NO. OF BLDGS. PITY L. X0.
SIZE OF LOT NOW ON LOT
USE OF DISTRICT�0. MAP
BUl DINGS �-
FF
BK PG
CONTRA CTO
CONr.CnON DATA
ADDRESS l V „
8raj STATION DEPTH
CITY TIL. X0, d ,YAM HOLE R4FEREMCC UPPER
STATE LOWER
REGISTVLAT70N N0.J O p . ❑ COUNTY
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTIO lFGTH FROM
PUBLIC SEWER f 3.60 Y. CURB .L.TO P.L.
fE IC TANK,SEEPAGE PIT ORy
FITS MD/04 DRAINFIELD 3.00 J
OVERFLOW SEEPAGE PIT,DRAIXFIELD Z.
P. , N0.
i
EATX. CESSPOOL,DRYWELLMANHOLE 2.00 CO. I P. N0. JO 0.
HOUSE SEWER CONNECTING TO
i PRIVATE DISPOSAL SYSTEM 1.00 / TRUNK PERK-IT NO. ROAD PERMIT NO,
CONNECT ADPITIONAL BLDG.OR STATE ENCROACHIAENT
WOR TO HOUSE SERER 1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE
INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® 1,00
WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWWEE'S PEE30T s 00
REIMBURSEMENT FEE
AUTHORMATION I TOTAL nM , o
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APnOVALS DATE INSPECT R'SSI6NATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXIpTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF CONNECT ADDITIONAL
OWNS; OR. BUILDING OR WORK �-
OWNERS AGENT SEPTIC TANK,SEEP, (S
ADDRES AND/OR DHAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
4CESSPOOL 0 DREW ELL ElND STATE THAT THE ABOVE IS CORRECT AND AGREE TO OMPLY
ITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I PEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES CO NTY AND STATE OF ABANDON 14OUBFSEWER
CALIFORNIA OR THAT I AY THE LEGAL O OF THE ABOVE
DESCRIBED RESIDE L PRO TY. BAC ILL SEPTIC TANKS❑
SIGNATURE BEEP.PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE0)17
.JOHN A. LAMBIE,CouNTY ENGINEER ALMATION ROBERT A.WOOD,CHIEF PL-BQ. INaP[CTOR
cf. ■.o. aAfN
61-9 4 50A NOV 2 4 10 A 6.0 0 2
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