HomeMy Public PortalAbout9502 OLEMA ST_Sewer__ 76A642D
jE808IREV.6/781 APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP MAP PROCESSED BY
BUILDING �' �"• ! > /� / �_ DK PG
ADDRESS
yy
LOCALITY CONNECTION DATA
�� � _ /
NEAREST STATION DEPTH
CROSS ST.
UPPER
MANHOLE REFERENCE LOWER
OWNER ''•� jj TYPE OF CONNECTION LENGTH P.L. ROM
ADDMAILRESS CI ry ,�^ �`- Y. CURB . M.L.TO P.L.
G< C,. L1,yP.C.NO.
CITY '�/ L.NO. CO.IMP.NO. JOB NO,
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
.DESCRIPTION LOT NO.
AFFIDAVIT I WAIVER I EASEMENT RECORD,INSTR.NO.I DATE
BLOCK TRACT
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT <
PERMIT NO.
CONTRACTOR / �.t! INDUSTRIAL
p �/ WASTE APPROVAL
ADDRESS -'d CHARGES
CITY •�.r� C�/ TEL,NO. CONNECTION CHARGE FEE
STATE l '7 r LIC. r ,� REIMBURSEMENT FEE
LICENSE NO. / - / CLASS �J ��+ C
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE U
HOUSE SEWER CONNECTING TO a
PUBLIC SEWER O
NEW HOUSE SEWER
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL Y
HOUSE SEWER CONNECTING TO BUILDING OR WORK fY
PRIVATE DISPOSAL SYSTEM
SEPTIC TANK,SEEP,PIT(S)
CONNECT ADDITIONAL BLDG.OR
AND/OR DRAINFIELD
WORK TO HOUSE SEWER r
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL ❑ DRYWELL❑
EXTN..CESSPOOL.DRYWELL,MANHOLE
ALTER,FjEPA1R OR ABANDON HOUSE ALTER.REPAIR,SEWER OR
SEWER OR DISPOSALSYSTEM SEWAGE DISPOSAL SYSTE M ')
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑
OWNER'S Permit SEEP,PIT(S)❑ CESSPOOLS❑
AUTHORIZATION TOTAL FEE l - VALIDATION
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON•
TRACTOR TOCONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_
OWNER OR
OWNERS AGENT
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE,1.MKS REGULATING
PLUMBING AND SEWERS.
I HEREBY CERTIFY THAT 1 PROPERLY EGISTIERED AND/OR
LICENSED AS REQUIRED BY SANGELES CO TY ND STATE OF
CALIFORNIA OR THAT I TH L&�GA WNER OF, D INTEND TO RE-
SIDE IN,THE ABOVE D 5. RI E�R 1 NTIAL PROPE Y.
SIGNATURE
OF PERMITTEE
CE80-9 3-64
76A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
SS
CRESS
AD 7
JOHN A. LAMBIE, County Engineer D
WILLIAM A. JENSEN, Supt of Building
LOCALITY
7
NEAREST
F.ROSS ST.
FOR APPLICANT TO FILL IN
DESCRIPTION LOT NO. OWNER
MAIL
A DDIR
BLOCK TRACT
NO, OFEILD GS.
SIZE OF LOT NOW ON LOT CITY
_TEL. NO.
USE OF PROCESSED BY
BUILDINGS DISTRICT NO.j,GROUP I BK MAP PO PR
CONTRACTOR /v/
ADDRESS CONNECTION DATA
TEL. NO. STATION DEPTH
'-e�o,
STATE MANHOLE REFERENCE UPPER
REGISTRATION 10'."2141-1-4- '01 COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CON NECT1ON LENGTH FROM
HOUSE SEWER CONNECTING TO @ Y. M.L.TO P.L,
PUBLIC SEWER $5.00 P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR CO,IMP.NO. JOB NO. 4.
PITS AND/OR DRAINFIELD $10.00 0
HO'j SE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO, U
PRIVATE-WSPOSAL SYSTEM S300
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER ZAStM RECORD.MSTR,NO. DATE ct'
WORKTO HOUSE SEWER @ $3.00
0
OVERFLOW SEEPAGE PIT,DRAINFIELD
FXTN CESSPOOL,DRYWELL.MANHOLE U
0 $5.00 HWY.OR ST.WIDENING LU
ALTER,REPAIR OR ABANDON HOUSE CL
SEWER OR DISPOSAL SYSTEM @ $3.00
STATE ENCROACHMENT
PERMIT NO. z
INDUSTRIAL
WASTE APPROVAL
OVMEWS PERMIT $ 2 00 — CHARGES
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
'IHAVr AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO THE ABOVE DESCRIBED EXISTING OWELLItLG
TO T H E PUBLIC SEWER. APPROVALS DATE INS CTOR'S SIGNATURE:
SIGNED THIS—DAY OF 19
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT
ONNECT
BUILDING OR WORK
ADDRESS— SEPTIC TANK.SEEP-PIT'(S)
I HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINF IIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL C OUNTYORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL [I DRYWELL El
HEREBY CERTIFY THATPROPERLY REGISTERED AND/OR ALTER,REPAIR,55WER OR
I AM
LICENSED AS REQUfREO BY LOS ST
ANGLES COUNTY AND, ATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA 00 THAT AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ApOVF DESCRIBED RES#IDENTIAL PjiC7PEfitTY.
ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PIT(S) [I CESSPOOLS El
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. e
M.O. CASH
4 24 5 L;0