HomeMy Public PortalAbout6537 OAK AVE_Sewer__ 76A6420
CE 8081REV.6/781
1�s APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT 30 FILL IN DISTRICT NO. GROUP BK PG MAP PROCES BY
Z IV rte,
ADDRESS `V. s'"T
y' G CONNECTION DATA-
LOCALITY
NEAREST y`�- STATION C/p A DEPTH
CROSS � l _ UPP R
•_� MANHOLE REFERENCE ER
OWNER .- i`
TYPE OFC ION LENGTH FRO
MAIL Y. CURB P.L. M.L.TO P.L.
ADDRESS
P.C.NO.
CO.IMP.NO. �j JOB NO.
CITY TEL.NO.
LEGAL T R U N y IT.NO �RERMIT NO. �
DESCRIPTION LOT NO.
AFFI A - AIVER EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT
NO.OF BLDGS. VI W
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE or
BUILDINGS _, - __- "''' _� STATE ENCROA T¢GN
c•.
PERMITNO. ,4-*-fA
CONTRACTOR INDUSTRIAL
WASTE APPROVAL
ADDRE CHARGES
CITY .a C+j N ..-7 ;,/,-�M „' a CONNECTION CHARGE FEE
STATE LIC. J REIMBURSEMENT FEE
LEGE NSE NO. Cf /
CLAS
N(?- DES RIPTIONF WORK FEE APPROVALS DATE I TOR'S SIGNATURE
V
HOUSE SEWER CONNECTING TO
PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER )
PITS AND/OR DRAINFIELD C
CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM 4
V
CONNECT ADDITIONAL BLDG.OR SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINFIELD Z
WORK TO HOUSE SEWER �
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL [I DRYWELL❑
EXTN.,C ESSPOOL.DRYWELL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑
Permit SSEEP,PIT(S)❑ CESSPOOLS❑
OWNER'S '
AUTHORIZATION TOTAL FEE % / VALIDATION
1 HAVE AT TH15 DATE A CONTRACT WITH THE HEREIN NA -TING TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING D
TOTHE PUBLIC SEWER.
SIGNEDTHIS L'�AYOF
OWNER OR
OWNERS AGENT ✓-+ L-..�
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPN
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TOYWITH ALL COUNTY ORDINANCES AND STATE LAWS REGPLUMBING AND SEWERS.
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTEREDRLICENSED AS REQUIRED BY LOS ANGELES COUNTY AND FCALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF.ANDINTE
SIDE IN,THE ABOVE DESCRIBED RESIDENTIAL PROPyE{RTY.
SIGNATURE y4i ,✓
OF PERMITTE J