HomeMy Public PortalAbout9807 OLIVE ST_Sewer__ �+Ab!a2f7
CE 6061 REV.bi78i
®5 APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP MAP CESSED BY
BK PG 7
BUILDING - 6 ✓ "' -
ADDRESS
CONNECTION DATA
LOCALITY ---
NEAREST STATION DEPTH
CROSS ST. _ _
4 UPPER
MANHOLE REFERENCE
OWNER,,-' - TYPE OF CONNECTION LENGTH FROM
MAIL . . - Y. CURB M.L.TO P.L.
ADDRESS
P.C.NO.
CO.IMP.NO. 2_ 7 JOB NO.
CITY ° °.---� TEL.NO.
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
CONTRACTOR - WASTE APPROVAL
ADDRESS CHARGES
CONNECTION CHARGE FEE
CITY TEL.NO. - -
STATE LIC. REIMBURSEMENT FEE
LICENSE NO. CLASS
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE (�
HOUSE SEWER CONNECTING TO
PUBLIC SEWER 0
NEW HOUSE SEWER
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG.OR SEPTIC TANK,SEEP,PITi5)
AND/OR DRAINFIELD
WORK TO HOUSE SEWER _
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL ❑ DRYWELL❑
EXTN.,CESSPOOL,DRYWELL,MANHOLE
BAN DON HOUSE ALTER,REPAIR,SEWER OR
SEWER OR SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUGAND E
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑
Permit y SEEP.PIT(S)❑ CESSPOOLS❑
OWNER'S VALIDATION
AUTHORIZATION I TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_
OWNER OR
OWNERS AGENT
ADDRESS
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
I HEREBY CERTIFY THAT I AM-PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF,AND INTEND TO RE-
SIDE IN,THE ABOVE DESCRIBED RESIDENTIAL PROPERTY.
SIGNATURE
OF PERM117E