HomeMy Public PortalAbout9123 OLEMA ST_Sewer__ ii
5A6420
E BDB(REV.B,B,) APPLICATION FOR PERMIT
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SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN CONNECTION DATA
ADDRESS ' �[....,_+ _,/� STATION DEPTH
LOCALITY +,r L ''. .f-• MANHOLE REFERENCE s9 UPPER
NEAREST TYPE OF CONNECTION Gr' LENGTH FROM
CROSS ST. I[•r .�'�"' Y. CURB P. M.L.TO P.L.
P.C.NO,
OWNER .IMP.NO. JOB NO.
MAIL TRUNK PERMIT NO, ROAD PERMIT NO. s"w
ADDRESS
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO, DATE 0
CITY TEL NO.
i.l
LEGAL � "st'J
DESCRIPTION LOT NO. HWY.OR ST.WIDENING
BLOCK TRACT /'^'� �l STATE ENCROACHMENT z
NO.OF BLDGS. PERMIT NO.
SIZE OF LOT NOW O LOT
USE OF
BU LDINGS / �, CHARGES
CONTRACT / t.C.T CONNECTION CHARGE FEE
ADDRESS "�->- -,.� IMBURSEMENT FEE
DISTRICT NO. GROUP MAP PROCESSED BY
STATE liC,�-•� j }�J _B/
LICENSE K PG
NO. � T CLASS--" / (� /ff
NO. DESCRIPTION OF WORK FEE FINAL
HOUSE SEWER CONNECTING TO fjK DATE VALIDATION
PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR NAL FI
PITS AND/OR DRAINFIELD FI
HOUSE SEWER CONNECTING TO By
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG.OR ►
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD -
EXTN.,CESSPOOL.DRYWELL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM
OWNER'S Permit g 0
AUTHORIZATION TOTAL FEE G
IHAVE AT THIS DATE A CONTRACT WITH THE HER NAMED ON RACTOR TO
CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
SIGNED THIS r DAYOWNE
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OWNER SAGE T + •+E- / r_Y
SEE REVERSE FOR EXPLANATORY LANGUAGE