HomeMy Public PortalAbout5745 OAK AVE_Sewer__ a°
cusooPPLICATION FOR PERMIT
ssos a Besa COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
MUTNIErTr OF COUNTY ENGIIiERB
BUILDING AND SAFETY DTiiISION BUILDING �•
ADDRESS
Mm A. Lapam Comdr mm
ase
CABBATT D GRIFM.5Wt of NuddmN LOCALITY EE•
NEAREST
FOR APPLICANT TO FU.L IN CROSS BY
DESCGAL
RIPTION LOT NOS'+ ® NER
BLOCK TRACT MAIL
id ADDRESS
NO OF BLD68
SIZE OF LOT NOW ON LOT I CITY TEL NO
USE OF
BUILDINGS 7colup
O GROUP BK MAP PG PROCESSED BY
CONTRACTOR i
CL+
ADDRESS
CONNECTION DATA
CITY _ L NO DEPTH
REGISTRATION NO � COUNTY REFERENCK
No DESCRIPTION OF WOR FEE LowER
HOUSE SEWER CONNECTING TO
PUBLIC SEWER S8 00
SEPTIC TANK SEEPAGE PIT OR OFC TION LENGTH FR
PITS AND DRAINFIELD S 00 URB P L M L TOP LOU
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRTwWLL MANHOLE S 00
HOUSE SEWER CONNECTING TO , P C NO
PRIVATE DISPOSAL SYSTEM $100 No JOB No
WORK TO HOUSEISEWER LD6 OR 1 TRUNK PERMIT NO ROAD PERMIT NO
SEWER ORD 8P08AABYNDON HOUSE 1 OO - STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WAST APPROVA
CHARGES
OwNWS PEMSIT s 2 CC CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEF REIMBURSEMENT
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPSOVAIS DATE INSPECTOR 8$IGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED STING DWELLING
TO THE PUBLIC SEWER
SIGNED THISAY OF I NEW xovsE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDR AND/ORTDRAINFC ARK EELD PIT(S)
I HEREBY A NOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL DRYWELL 13 1
LIDESCRIBED
COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
AND SEWERS SEWAGE DISPOSAL SYSTEM
Y CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
IA OR THAT M THE LEGAL OWNER OF THS ABOVE /�
RESIDENT P OPERTT BACKFILL
F IT S C CESSPOOOI S SLG /
EITTE
Lfaw" I
of AI.IDATION ROBERT A WOOD
AM+ M 0. G" >PNPSRVIMING ldac LANKA"SNaIm9m
L'08 8 3 3:S APR 5 1 0 A 5.0 0 �
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