HomeMy Public PortalAbout9712-9714 LONGDEN AVE_Sewer__ 76'A642D, -
`Ee081REV.6,78' 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
- CONNECTION DATA
LOCALITY �i✓"+f �.Y
NEAREST �„- "3'�'• _ STATION DEPTH
CROSS ST.
UPPER
) MANHOLE REFERENCE -
LOWER
OWNER s4
, ,r I=1 r�L TYPE OF CONNECTION LENGTH FROM
MAIL
ADDRESS _'� �-y"" LSV° �� i ". V. - CURB P.L. M.L.TO P.L.
`p \ CO.IMP.NO. JOB NO,
CITY M. ^l.._,-jx-- . TEL.NO.
LEGAL //''/ -- TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.f/'i
AFFIDAVIT WAIVER 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.
CONTRACTOR i ''_., a / INDUSTRIAL
v t. '� '✓ i�•' WASTE APPROVAL
ADDRESS ,LI >�� + �:L L`" &i:::.� .�� CHARGES
.. `� CONNECTION CHARGE FEE
CITY .. r - TEL.NO.
STATLIC. LL REIMBURSEMENT FEE
LICENSE NO. (( CLASS o
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE (�
HOUSE SEWER CONNECTING TO
PUBLIC SEWER "'j fr �•
SEPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER O
PITS AND/OR DRAINFIELD CONNECT
AL
HOUSE SEWER CONNECTING TO BUILDNG OR WORK
PRIVATE DISPOSAL SYSTEM
SEPTIC TANK,SEEP,PIT(S)
CONNECT ADDITIONAL BLDG.OR ANO/OR DRAINFIELD
WORK TO HOUSE SEWER �
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL ❑ 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❑
Permit S SEEP,PIT(S)OWNER'S
❑ CESSPOOLS❑
AUTHORIZATION TOTAL FEE VALIDATION
I 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 4 ,i4� = 79
OWNER R
O
OWNERS AGENT
ADDRESS
IHEREBY ACKNOWLEDGE THAT 1 HAVE READ4THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
I HEREBY CERTIFY THAT I AM PROPERLY REG]STE REL' AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY ANOj STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF,A DIN ND TO RE-
SIDE IN,THE ABOVE DESC RE T ROP d
SIGNATURE
OF PERMITTEE
76A6'12D • -
CE8081REV.6/781
ns APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP I MAP 'P iOCESSED BY
BK PG /
ADDRESS "'w /C'1L6'•�+G-/g`b`L' (''�".- ;i t....+R.^a,
LOCALITY >" �,l,;f'".. ,J C�. CONNECTION DATA
NEAREST ,G - STATION DEPTH
CROSS ST. zz 4fpJ 6 i�-. +' 1,,,,..._
j UPPER
OWNER 'E YW Z' ('i 7. �yty MANHOLE REFERENCE -
LOWER
TYPE OF CONNECTION LENGTH FROM
MAIL �- f —"•' Y. CURB P.L. M.L.TO P.L.
ADDRESS �E.° - ..r
P.C.NO. e
TEL.NO
CITY %� CO.IMP.NO, JOB NO. '
-. . .� .. t,� �:�
LEGAL _ - TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
y. AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT L
NO.OFBLDGS"
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
CONTRACTOR * i " i. act, � WASTE APPROVAL
ADDRESS « `t L- ,- `_'�y( 7 CHARGES
CITU TEL.NQ r --� rw CONNECTION CHARGE FEE
STATE y �+`-� LIC. REIMBURSEMENT FEE
LICENSE NO. CLASS
NO. DESCRIPTI N C5F WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE
u
HOUSE SEWER CONNECTING TO
PUBLIC SEWER ryry
SEPTIC TANK,SEEPAGE PIT OR - NEW HOUSE SEWER /' L-✓ .p 1-✓y -�-�
PITS AND/OR DRAINFIELD .rte
CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG.OR SEPTIC TANK,SEEP,PIT(S)
WORK TO HOUSE SEWER AND/OR DRAINFIELD
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL Q 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
OWNER'S Permit s
SEEP.PIT(S)❑ CESSPOOLS❑
AUTHORIZATION TOTAL FEE VALIDATION
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- -
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TOTHE PUBLIC SEWER. T!mss
51GNEDTHIS «- DAY,OF IZ f 19L[
OWNER OR
OWNERS AGENT .�
ADDRESS tyr
IHEREBY 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 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY,AND STATE OF
CALIFORNIA OR THAT 1 AM TH LEGAL OWNER OF,AND:INTEND TO RE-
SIDE IN,THE ABOVE DESfi1Tf� D RESIDE A�ROP �2TY.
SIGNATURE �,'eJ�/ ay
OF PERMITTEE +� '`�/,