HomeMy Public PortalAbout5731 NOEL DR_Sewer__ CE.64 D s ea
78A842APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION FAD
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TOHN A LAMM County EngIn oof
WILLIAM A JENSEN Sup t of Sud"g Ox
REST
FOR APPLICANT TO FILL IN BB BY
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DESCRIPTION LOT NO OWNER
MAIL
id
BLOCK TRACT ADDRESS S
NO OF BLD08
812E OF LOT NOW ON LOT CITY w D TEL NO2 `
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS
CONTRACTOR S"'01? BKOAA
3P�
ADDRESS N CONNECTION DATA
CITY TEL NO 6 3 S � STATION '3i.�� �
�} q. STATE HOL4JtEPERENCE ( UPPER
N
REGISTRATION NO (� / O COUNTY �} �� f OWE
NO DESCRIPTION OF WORK FEE TYPE OF CON CTION LENGTH FROM s� )
HOUSE SEWER CONNECTING TO Y RB P L M L
PUBLIC SEWER SS 00 V PC NO
SEPTIC TANK SEEPAGE PIT OR CO IMP NO 1 3 JOB NO 06
PITS AND/OR DRAINFIELD 810 00 O
HOUSE:EWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO V
PRIVATE DISPOSAL SYSTEM $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT •AMIR I 9422SBUT RECORD INBTR NODATE O
WORK TO HOUSE S!W!R $300T
OVERFLOW SEEPAGE PIT DRAINFIELD 11—
EXTN CESSPOOL DRYWELL MANHOLE 86 00
ALTER REPAIR OR ABANDON OUSE HWY OR BY WIDENING
B!W!R OR DISPOSAL SYSTEM t2 $300 STATE ENCROACHMENT U!
PERMIT NO Z
INDUSTRIAL
OWNERS
WASTE APPROVAL
O��fY NERS PERMIT s 2 00
CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE P!!
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXIBTINO DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTO 8 SIGNATURE
SIGNED THIS D Y OF 18_
OWNER OR NEW HOUSE SEWER '�
OWNER8 ADEN a CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK BEEP PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOB ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE L6 L OWNER OP AND INTEND TODISCONNECT PLUG AND
RESIDE IN THE ABOVE DESC la ESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTE BEEP PITIS) CESSPOOLS J�,3�
VALIDATION ROBERT A WOO
CK M O (cABN SUPERVISING MECHANICAL ENGINEER
LAL04 0 314 MY27 1 0 D 7.00« V