HomeMy Public PortalAbout9117 OLEMA ST_Sewer__ CE808 3-�
76A642D APPLICATION FOR PERMT
COUNTY OF LOS ANGELES SEWER—SEWAGE DIS'OOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS A
WILLIAM A. JENSEN, Supt of Building
LOCALITY ` 'i
JL
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T. j—��►
DESCRIPTION L07 NO. GW NERT '.J G?
MAIL + `''�
BLOCK TRACT i � ADDRESS_4 1 f � (V_a a
NO. OF BLDG$. -
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DIST R lCT NO. GROUP MAP PROC E55ED BY
BK P �/
CONTRACTOR
ADDRESS 3117 c i�� �, 4j..�. _ CONNECTION DATA
CITY TEL. NO. STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. u COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00 P.C.NO. >_
SEPTIC TANK,SEEPAGE PIT OR "--C' JOB NO. Q_
PITS AND/OR DRAINFIELD $10.00 GO. IMP, NO. O
.HOUSE SEWER CONNECTING TO I ' TRUNK PERMIT NO< ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM @
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wAIVEN u5EM ENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 I V
OVERFLOW SEEPAGE PST,DRAINFIELD
EXTN.,CES5POOL,DRYWELL.MANHOLE @ $5.00 + W
ALTER HOUSE i HWY.OR ST.WIDENING
SEWER!!R' 11115YSTEM $3.00
STATE ENCROACHMENT e - -
PERMIT NO. �("/ Z
INDUSTRIAL ✓.^-,�--
WASTE APPROVAL n,
rCHARGES E�
OWNERS PERMIT — $ 2; o0
,_-�- CONNECTION CHAYiGE FEE
AUTHORIZATION TOTAL FEE --
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT --
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS-
ASEPTIC TANK,SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY _-
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR f
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM 'I
CALIFORNIA OR THAT IAM TH E LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRi BED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
51GNATU REC�., Cxrv�>`>� BACKFILL SEPTIC TANKS ❑
OF PERMITTEE_ I J 1�N+117i ] `J
SEEP.PIT lS) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.0. CASH
and" J X
i2.53
5&&E-6"E-6
5 APPLICATION FOR PERMIT 1
-
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE D 1 SPOSA L
Department of County Ensineer
County of Los Angeles BUILDING '
WM,J.'FOX, COUNTY ENGINEERADDRESS �.
CASSATT D- GRIFFIN,SUPT Oir BUILDING yLOCALITY "'- � '
FOR: APPLICANT TO FILL IN NEAR sr.
LEGAL - ,..
DESCRIPTION L_07 NO.
BLOCK TRACT MAID'
NO OF BLDGS.
SITE OF LOT NOW ON,LOT ,-CIT ,,g, TEL.
USE OF
BUIL �� ) _ d _ -
..__I'DINGS------- ,._ �' —. DISTRIC NO. ROUP f P <
CONTaACTOR — '� P(�
i
ADDRESS A CONNECTION DATA
CIT . ]y ^.� TEL. STATION DEPTH -
^—^ C,--STATE ---� _—� A�A'vHO' R FERENC£ —
REGISTRATION N0. y m-f CI COUNTY _ I "-- _ LOWER
TYPE OP CONNECTION LENGTH FROM _
NO. DESCRIPTION OF MURK FEE - y -- P.L. M.L._TG P.L_.
�IHOUSE SEVIER CONNECTING TO
PUBLIC SEWER _ r_S 3.50
_I HOUSE.SEWER CONNECTING TO —
PRIVATE DISPOSAL SYSTEM _ 1.00
CONNECTADDITIGPdAt SLOG. OR
---�'` CO. IMP_ NO, JOB._a0. -
�N�RK TO HOUSE SEWER _ 1.00
_I x T_R OR REPAIR EX'S ING
SEWER OR DISPOSAL SYSTEM_ 1,00 TRUNK PERMIT IVO, ROAD PERMIT NO.
--- D.[-CON vi CT.4N0 ABINDON 5E`NER ---�- —I^—. STATE ENCROACHMENT '
_ I
AND_/O
R_ Y'T
D!SPQSAL SEM - _ - 1"00 ! _v PERMIT N0.
SEPTiC TANK,SEEPAGEPITOR _ - — — --�---_.NO.
---
?ITSAFd CiOR DRAINFiELD2.00 I INDUSTRIAL
CESSPOOL DR-WE _ - .--� _� WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00_1 CHARGES
PER
'—"�- --- CONNECTION CHARGE FEE
MIT s
AUTHORIZATION TOTAL FEE-i— REIMSURSEMENT FEE
I HAVE T'IS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DVsELLING APPROVALS DATE INSPECTORS SIGNATURE
TO THE PUBLIC SEWER
."'.� Y ,r" ;. :' ,.� NEW HOUSE SEWER.
SIGNED ,4 H;5 vDAY OOWNERO'qF
C014NECT ADDITIONAL
OWNERS 'Gr14-+'" "u-,.r t � �'-,k' `'� B UILDING OR WORK
. SEPTIC TANK T
SEEP, PIS)
fADDRE., .tI AND;OR DRAINFi F.LD _
I HER BY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL[j DRYWELL[I
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER., REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM_
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUS AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWED.
CALIFORNIA OR THAT I AES THE LEGAL OWNER OF .THE ABOVE ---
DESCRIBED RESIDENTIAL PROPERTY. / BACKFILL SEPTIC TANKS
SEEP. PIT(s) 0 CESS COLS
SIGNATURE
OFPERMITTEE'
" -
t-
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
BY BY
DEPUTY DEPUTY
BY BY
0 DEPUTY DEPUTY