HomeMy Public PortalAbout9708-9710 LONGDEN AVE_Sewer__ a
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7686428
CE
®S 8081REV.6/781 APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. 1 GROUP MAP PG PROCESSED BY
BK
BUILDING
ADDRESS
�--Y CONNECTION DALOCALITY
TA
NEAREST +�,rt STATION DEPTH -
CROSSST.
UPPER
- ./t.,,, ]� MANHOLE REFERENCE - LOWER
OWNER y _ _,-j.�G.�{�' .a .�•'�� `S TYPE OF CONNECTION LENGTH FROM
ADDRESSMAI L _� C%'" -'`.r 'Y,. CURB P.L. M.L.TO P.L.
P.G.NO.
CO.IMP.NO. JOB NO.
CITY .— - TEL.NO.
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOTNO. ,
_ AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT A
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
STATE ENCROACHMENT
BUILDINGS
PERMIT NO.
CONTRACTOR �,. `` INDUSTRIAL
�.} z- f' YI. WASTE APPROVAL
ADDRESS CHARGES
� .:' t76t1 SSC .
CITY r .---�,.�, TEL.NO. ° +� CONNECTION CHARGE FEE
X
�STATLICENSE NO.
, �r �' CLASS REIMBURSEMENT FEE
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S. IGNATURE {,
HOUSE SEWER CONNECTING TO l
PUBLIC SEWER -
SEPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL W
HOUSE SEWER CONNECTING TO BUILDING OR WORK YYY4iiii
PRIVATE DISPOSAL SYSTEM 0.
CONNECT ADDITIONAL BLDG.OR SEPTIC TANK,SEEP,PIT(S)
WORK TO HOUSE SEWER AND/OR DRAINFIELD _
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL 0 DRYWELL
EXT N..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 11
OWNER'S
Permit $ SEEP.PIT(S)❑ CESSPOOLS
AUTHORIZATION I TOTAL FEE - VALIDATION
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIELED EXISTING DWELLING - -
TO THE PUBLIC SEWER.. 1,y d
SIGNED THIS DAY OF ' �''` �--',J�,. 19
OWNEROR
OWNERS AGENT tJ.I�• ib'4J Y- �r}l�'" ^��--' QMI ..
ADDRESS `✓'!
I HEREBY ACKNOWLEDGE THAT I 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 CQYINTY AND STATE OF
CALIFORNIA OR THAT I AM HE LEGAL OWNER Off' A 1x INTEND TO RE-
SIDE IN,THE ABOVE DE� BED. SIDE IAL/7R(ROPRTY.
SIGNATURE
F fr I
OF PERMITTEE -
r _
7&9642a
`Ee°BIKE
t5 APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP BK PG MAP PROCESSED BY
BUILDING
ADDRESS
%--
LOCALITY CONNECTION DATA
_ L�
NEAREST STATION DEPTH '
CROSS ST.
UPPER
MANHOLE E OF CONNECTION I REFERENCE LEND Y, � LOWER
OWNER �L-s4-'.. �. r
GTH FROM
MAIL f_ CURB P.L. M.L.TO P.L.
ADDRESS � IC jJ"E l3rf"_� / i4�/��,'
' P.C.NO.
CO.IMP.NO. JOB NO.
CITY � TEL.NO,.
LEGAL - TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION �6dii.910'. � '�.Jt J
WAIVER EASEME
K AFFIDAVIT NT RECORD.INSTR.NO. DATE
BLOCK TRACT
..5 ..._`.7 r ?
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
CONTRACTOR s /' k. �'�'G -4'T- INDUSTRIAL
WASTE APPROVAL
}r
ADDRESS +�V (x.." — yJ.I � i A y�..YL'.' i CHARGES
r CONNECTION CHARGE FEE
CITY ` - TEL.NO. G
STATELIC.
�+�^, REIMBURSEMENT FEE
LICENSE NO. �' .... CLASS jrr7""
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE (�
HOUSE SEWER CONNECTING TO
PUBLIC SEWER
NEW HOUSE SEWER
SEPTIC TANK,SEEPAGE PIT OR
PITS AND,/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM
SEPTIC TANK,SEEP,PIT(S)
CONNECT ADDITIONAL BLDG.OR AND/OR DRAINFIELD
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL J DRYWELL
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
SEEP,PIT(S)❑ CESSPOOLS❑
OWNER'S Permit s
AUTHORIZATION TOTAL FEE VALIDATION
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TOTHE PUBLIC SEWER, ry^
SIGNEDTHIS DAY OF - 19OWNEROR
Lj '
OWNERSAGENT
ADDRESS fro 2/,. �.Ga".D i.. /' ..� '162("1
<'
IF
I HEREBY ACKNOWLEDGE THAT I 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 COUNTOPEY A STATE OF
CALIFORNIA OR THAT I AM THE L AL OWNER OF. AlD END TO RE-
SIDE IN.THE ABOVE DESCR191_D ES.IDE NTIALPd
rYY f
SIGNATURE
OF PERMITTEE -