HomeMy Public PortalAbout6235 OAK AVE_Sewer__ 76A642.D
Elecs 11_nl� APPLICATION FOR PERMIT
1XVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
1
FADDRESS
JOHN A. LA�ABIE, COUNTY ENGINEER
CASSATT D.GRIFFIN, SUPT OF BUILDING LOCALITY
EAREST
FOR APPLICANT TO FILL IN CROSS ST._
LEC OWNER
_2ESCRIPTL9_�_ LOT ti4�I j-
T 14AIL
BLOCK TRACADDRESS
NO. OF BL065.STZE OF LOT' NOFV ON LOT
CITY TEL. NO,
USE OF
_BUILDINGS DISTRICT NO, GROUP MAP
K P G
CONTRACTOR
ADDRESS CONNECTION DATA
STATION
CITY TEL.NO. _j_L_y DEPTH
MANHOLEREFERENCE
STATE LOW
REGISTRATION NO. Z' COUNTY
NO:. I` DESCRIPTION OF WORK FEE _LENGTH_
FROM
NG To TYPE OF
ISE SEW COMWEI5TI CURB P.L. M.L.TO P.L.
n IqsE%YER ca"
SEPTIC TANK, EPAC- PIT OR
PITS AND/OR DRAINFIELD c. s 3."o
P. C. NO.
EXTN..CESSPOOL,DRYWFLL,MAN SOLE $2,00 CO. IMP, NO. JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM rzr s 1,00-! TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL SLDG.OR
WORK TO HOUSE SE,'jF.R s 1.0c, STATE ENCROAC14MENT
PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
I SE'hEP OR DISPOSAL SYSTEM .Go WASTE APPROVAL
_4 CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT 00
REIMBURSEMENT FEE
AUTHORIZATION
I HAVE AT THIS DATE A CONTRACT WITH 'THE HrREiN NAMED CON-
APPROVALS DATE. !NSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO TIE PUBLIC SEWER, NEW HOUSE SEWER
SIGNED THIS.------DAY 'CNNECT ADDfTIONA1
OWNER OR BUIILDING OR WOR'K
OWNERS ��EAGENT - PTIC TANK,SEEP,
_AD AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATIONCESSPOOL L] DRYWELL 0
AND LT TE THAT THE ABOVE IS CORRECT AND AGREE To COMPLY
WITHT
ALL "00,NTY ORDINANCES AND STATE LAWS REGULA ING ALTER. REPAIR,SEWER OR
a
PLUM 1XG 1 N SEWER$, SEWAGEDISPOSAL SYSTEM
I 3Y CFkTIFY THAT I AM PROPERLY REGISTERED ANVUR.
LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR T!z'AT I AM THE LEAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PRO PER _1AC.I',Fi LL SEPTIC TANKS❑
SIGNATURE SEEP. PIT(S) L! CESSPOOLSC-
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A. WOOD. CHIEF PLEIG. INSPECTOR
CK. M.C. CASH
a. r
2 0 1 2 JM p
0 A 5.0 0