HomeMy Public PortalAbout5004 PAL MAL AVE_Sewer__ '6A 642D-CESOB�10,71, . APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION [BUILDING
ADDRESS
LOCALITY . ,..(�.
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
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DESC RGPTLfON LOT NO. OWNER /� /L.ar1F'�..'I /` ') /�y({,(y/r✓(,� ( J �e
MAIL .� fI' / J/.+ K../ ! (e
BLOCK TRACT ADDRESS
SIZE OF LOT NOWOONB LOTS CITY f TEL. NO. T �rt,
USE OF DISTRICT N0. GROUP MAP PROCEjS5ED BY
BUILDINGS
--__ _ yB Kms+ P/S'� / J
CONTRACTOR .—T7 LC"'��.� {/+J
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ADDRESS CONNECTION DATA
CITY TEL. NO. _
STATE LIG STATION DEPTH MANHOLE REFERENCE UPPER
LICENSE_NO. - CLASS LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTIONL GTO
FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. .L.TO P.L.
PUBLIC SEWER @ $7.00 .C.NO.
SEPTIC TANK.SEEPAGE PIT OR JOB NO.
PITS AND/OR DRAINFIELD @ 510.00 CO. IMP. NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM $3.00 TRUNK PERMIT NO. ROAD PERMIT NO. Q
CONNECT ADDITOIONAL BLDG.OR AFFIDAVIT WAIVER E HENT RECORD.INSTR.NO. DATE 0
WORK TO HOUSE SEWER 53.00
OVERFLOW SEEPAGE PIT.DRAINFIELD _ OC
SSPOOL.DRYWELL. @ $5.00 O
LTER, AIR OR ABANDON HOUSE �- HWY.OR 5T. IDENING v
5 OR DISPOSAL SYSTEM 53.00 _ STATE E ROACH HENT
$7.00 FERMI O.
MANHOLE n
---- ---- IN STRIAL
W STE APPROVAL 2
WR
ONES PERMIT $ 3 00 CHARGES
AUTHORIZATIONJ TOTAL FEE / • CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED COIN- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF _19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY -
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER..RLPM!FR,SEWER OR -X
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF ;kEWAGV4"e.0SSAL SYSTEM !
CALIFORNIA OR THAT AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE j
ABO E DECF?IBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE 1 f y", y
_ .. ""ABACKFILL SEPTIC TANKS
OF PERMITTEE
❑
SEEP,PITS) �SSPPOOLS ❑
VALIDATION CK, M.0. CASH
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