HomeMy Public PortalAbout5011 PAL MAL AVE_Sewer__ WWI
APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FAD
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FOR APPLICANT TO FILL IN ST.LE GAL
DESCRIPTION LOT NO. 1 _ OWNER ` j 6
MAIL
BLOCK TRACT ps( --�,.� j-" ADDRESScap
NUSIZE OF LOT (t..' t,l NOW OONB LDG
p LOTS. F CITY CI l �EL. NO. �V L
USE OF r y4 t�.+,�, ISTRICT NO. GROUP MAP ESSED BY
BUILDINGS 'U ,S `✓ (�^ �/ GL�. �CJ1" SK PG -R& C
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CONTRACTOR _ •. a
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ADDRESS CONNECTION DATAp
V STATIONp } DEPTH Y
CITY TEL. NO.
STATE LIC MANHOLE REFERENCE ?yam
LICENSE NO. CLASS L ;�^-(,.� A', yJ LOWER
NO. I DESCRIPTION OF WORK FEE TYPE OF CQI,�,,,ECTION LENGTH FROM!
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L TO P.L. p
PUBLIC SEWER @ $7,00 /�
SEPTIC TANK,SEEPAGE PIT OR _ P.C.NO.
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. ;X. JOB NO.
_ _
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. CL Ct
PRIVATE DISPOSAL SYSTEM $9.00 O
-� CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVax -useK[nr RECORD.INSTR.NO. DATE V
WORK TO HOUSE SEWER $3.00 JZ.%
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL.DRYWELL. @ $5,00 O
A
ALTER.REPAIR OR BANDON HOUSE HWY.OR ST.WIDENING I.
SEWER ODISPOSAL SYSTEM $3.00 STATE ENCROACHMENT Lu
R Lu
MANHOLE PERMIT NO; C.
.$7.00 to
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $
AUTHORIZATION TOTAL FEE L9 CONNECTION CHARGE FEE `-- —
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING — _--
TO THE PUBLIC Sl:W. f R �—Vy APPROVALS DATE INSPECTOR'}§SIGNATURE
SIGNED THIS �+` �DAY OF / C b ___19 `--OWNER OR OR - , �� NEW HOUSE SEWER
OWNERS AGENT y y M CONNECT ADDITIONAL
ADDRESS_ 1-._(-,'_.. `'4�_J_L , _ BUILDING OR WORK!
SEPTIC TANK,SEEP.PITS)
I "
ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY -- ---
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR ,
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALI.FORN IA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
REST DE IN, THE ABOVE DES RIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIOF APERMTTTURE TEE ___ __ BK]FILL SEPTIC TA.NIC S. :1
5 EP PIT(S) ❑ .s ESSPOOLS ❑ '�jii�. �'�+ „)y,w i, -�
VALIDATION CK .f M.O. CASH
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