HomeMy Public PortalAbout5019 PAL MAL AVE_Sewer__ 124690 IN�6S ' s
` s_6° APPLICATION FOR PE MIT
�6A$76A$421) COUNTY OF OS ANGELES SEWER--SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION B u I LD1 N G -y
ADDRESS ,.���
JOHN A. LAMBIE. CouatY Enuaneea
WILLIAM A. JENSEN, Sap t of Building _LOCALITY -
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. X -'
LEGAL OWNER ' < °J� $ 1�- ay.. ,r�,'��'i•'
DESCRIPTION LOT NO.
:BLOCK TRACT _,yam ADDRESS -MAIL
'14
v NO.OF BLDGS.
SIZE OF LOT✓ < . � � (A NOW ON LOT j CITY �� 2 ��1 TEL. NO,.&e-
�
USE OF
BUILDINGS DISTRICT Nb.I GROUP ° MAP P OCESSED BY
BK PG
CONTRACTOR° ,+6 I,:m
ADDRESS CONNECTION DATA
CITY "y� TEL.NO . STATIONDEPTH p
STATE MANHOLE REFERENCE ' UPPEit-..
REGISTRATION_NO. COUNTY LOWER.
NO.iDESCRIPTION OF WORK FEE - --
HOUSE SEWER CONNECTING TO _
PUBLIC SERER to $3.00 TYPE OF_rOryECTION LENGTH FROM —
SEPTIC TANK.SEEPAGE PIT OR Y. �CURB`` P.L. M.L.TO P.L.
ITS AND/OR DRAINFIELD @ $3.00 -
OVERFLOW SEEPAGE'PITT DRAINF'IELD
_ EX N.,C-.SSP001 DRYWELL @ $2,00
HOUSE SEWER COVNECTINGTOP.C.NO. -
PRIVATE DISPOSAL SYSTEM @ $1..00 CO.IMP. NO. '; JOB N0.
CONNECT ADDITIONAL BLDG.OR � TRUNK PERMIT NO. ROAD PERMIT NO. �J " Ak
WORK TO HOUSE SEWER @ $1.00 ? • ')�r - ---
A ,FR, rcFPAIR 1 R ABANDON HOUSE STATE ENCROACHMENT
• SEWER OR DISPOSAL SYSTEM @ $1_00 _ PERMIT N0.
INDUSTRIAL
C?
_- - WASTE APPROVAL W
o<
CHARGES rn
OWNER'S PERMIT s E 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEEREIMBURSEMENT FEE _
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEINER. r `f
SIGNED THIS DAY OF ;°'"� �" 19'��' NEW HOUSE SEWER
OWNER ORCONNECT ADDITIONAL
OWNERS AGENT k.``�� t °- "" %' '� BUILDING OR WORK
ADDRESS ' , �' �+'` ��^s''. M SEPTIC TANK,SEEP,PITS)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT t HAVE READ THIS APPLICATION
AND .STATE THAI' THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL 0 DRYWELL ❑
WITH ALI.. COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR,SEWER OR
PLUMBING AND SEWERS, SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RE DENTIAL PROPERTY- BACKFILL SEPTIC TANKS
SIGNATURE SEEP.PIT(S) [ CESSPOOLS [l�_ �_...
OF PERMI7TE� '
VALIDATION'-— ROBERT A. WOOD
cr. M.0. d"CASH SUPERVISING MECHANICAL ENGINEER
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