HomeMy Public PortalAbout9809 OLIVE ST_Sewer__ 76At,42C
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o= APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. I GROUP BK FG MAP PROCESSED BY
BUILDING -- � -
ADDRESS
CONNECTION DATA
LOCALITY
NEAREST STATION DEPTH
CROSS ST.
UPPER
-- MANHOLE REFERENCE LOWER
OWNER
TYPE OF CONNECTION LENGTH FROM
MAIL Y. CURB P.L. M.L.TO P.L.
ADDRESS
P.G.NO.
CO.IMP.NO. JOB NO.
CITY TEL.NO.
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT
NO.OF BLDG S.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
CONTRACTOR - WASTE APPROVAL
ADDRESS CHARGES
CITY TEL.NO. CONNECTION CHARGE FEE a
STATE LIC. REIMBURSEMENT FEE O
LICENSE NO. - CLASS
NO. DESCRIPTION OF WORK FEElJ.l
APPROVALS DATE INSPECTOR'S SIGNATU
HOUSE SEWER CONNECTING TO _
PUBLIC SEWER
NEW HOUSE SEWER
SEPTIC TANK,SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD
CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK 117 1�1
PRIVATE DISPOSAL SYSTEM O
SEPTIC TANK,SEEP,PIT(S)
CONNECT ADDITIONAL SLOG.OR
WORK TO HOUSE SEWER AND;OR DRAINFIELD
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL [I DRYW ELL
EXTN.,CESSPOOL.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
SEEP.PIT(SI❑ CESSPOOLS J
OWNER'S Permit s
AUTHORIZATION TOTAL FEE VALIDATION
I 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
IHEREBY ACKNOWLEDGE THAT I 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 PE RM ITTE E