HomeMy Public PortalAbout6390 OAK AVE_Sewer__ CC.al)BA 4/72
A7 5 A64 2 L APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING II'
I' SS
ADDRESS ga'�
LOCALITY
fNE7AREST
FOR APPLICANT TO FILL IN CROSS ST.
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DESCRIPTION, LOT NO. OWNER W ER A e4�- bl__
MAIL
BLOCK TRACLr" ADORES
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NO. OF BLOGb.
SIZE OF LOT NOW ON LOT CITY Pl-j$A NO.
USE OF
DIST UP�
.DISTRICT NC.j(-;R() �ZOCESSI
BUILDINGS SK MAP -11 BY
NTRACTORfin b
ADDRE Is IS 4 CONNECTION DATA
ON
A 411 TEL. NO. 9 4. 4i94��
STATI
STATE LIC UPPER
GLASS -'
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LICENSE '10.3 Z-4-6V MANHOLE REFERENCE
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGtH FROM
HOUSE SEWER CONNECTING TO 'Y.y P.L. M,L.'OP.L.
PU BLiC SEWER
7 P-C.NO.
S PITS AND/OR DRAINFIFLD CO.IMP.NO.
SEPTIC SEEPAGE PIT OR JOB No�
0
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO, ROAD PERMIT NO.'-
_--pRiVATE DISPOSAL SYSTEM @
ADDITIONAL ITLDG. ikMb IT wAmR; D. Ni-iR.NO, I DATE
�.:ONNF'�� iOR
V HOUSE SEWER @
0
OVERFLOW SEEPAGE PIT.DRAINFIELDu
EXTN.CESSPOOL.DRYWELL.MANHOLE: Lu
ALTER,REPAIR OR ABANDON
HOUSE HWY,OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @STATE EN CROACH MEN7 LI)
PERMIT NO. z
INDUSTRIAL
WASTE APPROVAL
OVirNER'S PERMIT -z' CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE',-�:
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON, REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXf STING DWELLING
70 THE PUBLIC SEWER APPROVALS --DATE INSPECTORS SIGNATURE
SIGNED THIS._._.DAY OF-- _19-
OWNER OR NEW HOUSE SEWER
OWNERS AGENT----
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP,Prr(s)
IHEREBY ACKNOWLEDGE THAI I HAVE READ THIS AU
PPLICATION AN ,'QR DRAI NF IrLD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
W;THALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
RS. CESSPOOL ❑ DRYWELL
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIR LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
ED By
SIDE N. ;OVr --�.X'RE.I[I�W;iAL PROPE. Y. SEAN D
CALiFORN A OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO Ol SCONNECT PLUG
RE: ABANDON HOUSE WER
SIGNATURE TIC
OF PERM."Trr EIACKFfLL SEP
SEEP,PIT IS) ❑ CESSPOOLS 131
VALIDATION
M.O. CASH
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