HomeMy Public PortalAbout9605-9607 LONGDEN AVE_Sewer__ 76A642D
CE
s 808(REV.6/781 APPLICATION FOR PERMIT -
rP
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP MAP PRO E ED 8Y
BK PG
B UILDIN t� / '� /1 �'+ / 4 f
�v
/9 CONNECTION DATAJ
LOCALITY ,L -
NEAREST _ STATION �1 f - DEPTH
CROSS ST. •- r` t
UPPER
�r MANHOLE REFERENCE LOWER
OWNER .' ,!7 L/`�,
TYPE OF CONNECTION LENGTH FROM
MAILADDRESS �( - ,o Y. CURB P.L. M.L.TO P.L.
P.C.NO.
CO
CITY 1Tf,-G, - fy" TEL.NO. L-� -� .IMP.NO. JOB NO.
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFFIDAVIT WAIVER I EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF .
BUILDINGS - STATE ENCROACHMENT
PERMIT NO.
;- !py-fjr INDUSTRIAL
CONTRACTOR
WASTE APPROVAL
ADDRESS CHARGES
CITY .w a TEL.NO. CONNECTION CHARGE FEE
STATE LIC. REIMBURSEMENT FEE
LICENSE NO. CLASS
NO. DESCRIPTION OF WORKO
FEE APPROVALS DATE INSPECTOR'S SIGNATURE
V
HOUSE SEWER CONNECTING TO -
/J PUBLIC SEWER O
SEPTIC TANK.SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK WW
PRIVATE DISPOSAL SYSTEM d
SEPTIC TANK,SEEP,PIT(S)
CONNECT ADDITIONAL BLDG.OR I/1
WORK TO HOUSE SEWER AND/OR DRAINFIELD Z
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL [3DRYWELL❑
EXTN.,CESSPOOL.DRYWELL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑
OWNER'S
Permit $ SEEP,PITISI❑ CESSPOOLS J
--
AUTHORIZATION TOTAL FEE / r- VALIDATION /ry>
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_
OWNER OR
OWNERS AGENT
ADDRESS
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF,AND INTEND TO RE-
SIDE IN.THE ABOVE DESCRIBED RESIDENTIAL PROPERTY.
SIGNATURE '
OF PERMITTEE - y,'
76A6d2D
CE8081REV.6/781 APPLICATION FOR PERMIT
:pJ S
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN o1sTR1cT No. GROUP MAP P ESSED BY
BUILDING _ B�b r aPG
ADDRESS 1.,1'67 =..=
LOCALITY CONNECTION DA
/+� � L�-�s'� .(
NEAREST STATION �,7 .ri,./ DEPTH
CROSS ST. 17 � +!' + 3 !
UPPER
MANHOLE REFERENCE LOWER
OWNER
'� G� TYPE OF CONNECTION LENGTH FROM
MAIL � J- .- Y. CURB P.L. M.L.TO P.L.
ADDRESS
P.C.NO.
j - CO.IMP.NO. JOB NO.
CITY ,J` - } TEL.NO.
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO. � �"�
AFFIDAVIT WAIVER I EASEMENT RECORD.INSTR.NO. DATE
.BLOCK TRACT �-
NO.OF SLOGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS r -,s STATE ENCROACHMENT
- ,,yy �j PERMIT NO.
INDUSTRIAL
CONTRACTOR ��L3 i �pFyG loTfY K/ WASTE APPROVAL
ADDRESS rs_' CHARGES
CITY TEL NO. CONNECTION CHARGE FEE
STATE LIC. REIMBURSEMENT FEE
LICENSE NO. CLASS
NO, DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTORS SIGNATURE V
HOUSE SEWER CONNECTING TO -
�`' PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL Y_
HOUSE SEWER CONNECTING TO BUILDING OR WORK YYYiii
PRIVATE DISPOSAL SYSTEM IA
CONNECT ADDITIONAL BLDG,OR SEPTIC TANK,SEEP,PIT(S)
WORK TO HOUSE SEWER AND/OR DRAINFIELD _
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL ED DRYWELL❑
EXTN.,CESSPOOL,DRYWELL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE ALTER,REPAIR.SEWER OR
SEWER ORD ISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑
OWNERS Permit s SEEP,PITISI❑ CESSPOOLS El
' M-
AUTHORIZATION I TOTAL FEE j VALIDATION
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TOTHE PUBLIC SEWER.
SIGNED THIS DAY OF 19_
OWNER OR
OWNERS AGENT
ADDRESS
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LIGEN5ED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THELEGAL OWNER OF.AND INTEND TO RE-
SIDE IN,THE ABOVE DESCRIBED RESIDENTIAL PROPERTY.
SIGNATURE l
OF PERMITTEE -