HomeMy Public PortalAbout5823 OAK AVE_Sewer__ 76A :420—CE803—10 71 I APPLICATFOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING _
ADDRESS !� /�
LOCALITY T L c d
NEAREST
FOR APPLICANT TO FILL IN CRD:B BT
LEGAL
DESCRIPTION LOT NO OWNER f,
MAIL
BLOCK TRACT / ADDRfiB6
NO OF BLDGb
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP SK MAP P PRO ESSED BY
BUILDINGS
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//JJ , � CONNECTION DATA
r TEL NO 1► STATION O� DEPTHII��QQ�� LIC ` 3/ MANHOLE REFERENCE �( . �j.0UPP NO pCQ(Q �� OLA88 ` V (p /�/DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
LIC 9EWERCONNECTING TO s7 00 0� Y CURB M L TOPLTIC TANK SEEPAGE PIT OR J C NO
HOUSE SEWER
AND/OR DRAINFIELD e 31000 CO IMP NO 1 JOB NO
SE:EWER CON NECTI NO TO TRUNK PERMIT NO ROAD PERMIT NO OVATE DISPOSALSYSTEM 3300
NECT ADDITIONAL BLDG OR AFFIDAVIT RAIY[[ [A[[N[NT RECORD INSTR NO DATE 0RK TO HOUSE SEWER5300RFLOW SEEPAGE PIT DRAINFIELD ON CESSPOOL DRYWELL SS 00 HWY OR ST WIDENING
ALTER REPAIR OR ABANDON HOUSE v
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT W
MANHOLE ;7 00 PERMIT NO O.
INDUSTRIAL h
��+p WASTE APPROVAL Z
O V��YA R S pERWT $ 3 00 CHARGES
AUTHORIZATION TOTAL FEE O O\ CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED COON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING AOVA
TO THE PUBLIC SEWER DATE INSPECTORS SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER i
OWNERS AGENT r CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK BEEP PIT(:)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
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
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF AND INTEND TODISCONNECT PLUG AND
RESIDE IN THE OVE DESCRIBED REBID AL PROPERTY ABANDON HOUSE SEWER
SIGNATURE / BACKFILL SEPTIC TANKS
OF PERMITTEE SEEP PITS) SPOOLS ❑
VALIDATION CK M 0 CASH
OFEB 5 i 0 A �. 0.0 0 w!Jb