HomeMy Public PortalAbout10226 GREEN ST_Sewer__ 7F/GB'-°'
7BA641D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN.A. LAMPIE. COUNTY ENGINEER AooRW
COLEMAN W. JENKINS.SUPT. OF BUILDING
LOCALITY
M BAREST
FOR APPLICANT TO FILL IN CROS ST.
DESCRIPTION LOTH OWNER
MAIL
■LOCK TRACT ADDRESS /-j" 71
NO. OF 11111-1009.
SIZE OF-LOT I j Plow ON LOT CITY TIL. NO.
US[ F ODISTRICT NO. GROUP I MAP
USIL OF FROG'WED BY
CONTRACTORUa }�
ADDR[M D CO�CTj ATA
STATION .DEPTH
CITY NO.
7,7
/TAT[ LIC
/�
LIC[NS[ Hzezb 0 CLASS[.�r f,Z MANHOLE R[F[II[NCI
NO. .01-rSCMPTION OF WORK" FEE TYPE OF CONNECTION LJNGTKlFRbm
110U/E■EWER CONNECTING TOW $5.00I[
O�y CURE P.L- M.L TO F.L d
i�
PUBLIC SBER $5.00 V --
O DTIC TAN ■[ AO[PIT OR PCO. O
PITC AND/OR DRAINFIELD ff0.00 C.Q.IMP.NO. ) �Ij?• V
HODS[SI[W[R CONNECTING TO TRUNK PERMIT NO. ROAD PERYIT NO.
PRIVATE DISPOSAL SYSTEM 86.00 O
CONNECT ADDITIONAL BLDG.OR L) AFFIDAVIT EA!►n Uf[tr n'f RECORD.INSTR.NO. DATE
WORK TO HOU;[;[W[R f1A0 (,J
[RFLOW;[[PAG[PIT,DRAINFIELD d
F%T N..CEI;PO O L.DRYW[LLMANHOL[ MOO In
ALTER.RPAI O A ABDO O HWY.OR ST.WIDENING Z
SEWER OR DISPOSAL SY/TEM 81.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL _
WAWiE APPROVAL
OWNER'S PEHMTf f 2 00 CHARGES
,-
A=ORTLATION I TOTAL F) CONNECTION CMAROE FI[
I HAV[ AT THISDATE q T-
HK WITH T [ HEREIN NAMED CON- REIMBURdKM[Nt?fftE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXIWTINO DWELLING
TO'7HE PUBLIC /[WKPt. G" AEOV�s DAT* S 11
HB R'S/10ATU R[
SIGNED THIS DAY OF.�Y/ 1Qj-
OWNER OR /1 �D� NEW HODS[-SIH
WE `
OWNERS AO[NT_ 1.LG� CONNILT ADDITIONA-L /
■U I1.D1 NO OR WORK F j
ADDR[;/ SEPTIC TANK,SEP,PIT(S) f
I HEREBY ACKNOWLEDO[ THAT I HAVE READ THIS APPLICATION AND/OR DMINFIXIM
AND BTAT[ THAT THE ABQV[ 16 CORRECT AND AORCOMPLY -
WITH
[[ TO
ALL COUNTY ORDINANCES AND STATE LAWS REOULATINO
FLU MBING AND SSW[RS. CESSPOOL ❑ DRYWELL ❑
IHERESY C[RTfFY THATR
1 AM PROPERLY ROISTERED AND/OR ALTiR,REPAIR.SEWER OR
LICENSED AS JRKQUIRED LO ANGLES COUNTY AND STAT[ OF ■SWAG[DIBTO/AL SYSTEM
CALIFORNIA OR THAT LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG ANP
R ESIDF IN, THE AS RIBEb RESIDENTIAL PROPERTY. ABANDON HOU61[EEWER
SIONATUR[ GAC KFIL.L
OF PERMITTEE C[S;POOLJ g,a R .
VALIDATIO JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
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