HomeMy Public PortalAbout5122 PAL MAL AVE_Sewer__ a42D
6S 11-55 APPLICATION FOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE', COUNTY ENGINEER ADDRESS
IN, SUPT OF BUILDING
CASSATT D. GRIFF LOCALITY Y
N I
NEAR EST
FOR APPLICANT TO FILL IN ST.
LEGAL
D 7 OWNER
DESCRIPTION LOT NO.
Z--- MAIL
BLOCK TRACT
4ADDRESS
NO OF BLDGS.
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NOW ON LOT CITY NO. Az,
�LZE OF LOT
USE OF
BUILDINGS. , DISTRICT NO. GROUP MAP
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BK PG
CONTRACTOR
CONNECTION DATA
ADDRES'S
z
MANHOLE REFERENCE
—[—ISTATE' COWER
REGISTRATION I
❑ COUNTY
N0 D-E—S E�_IPT—i 6N GF W/R/�'T FEE
TYPE OF-CONNE-C ION
HOUSE SE'NER CONNECTING TO LENGTH FROM
:5��A, -v CURB, P.L. M,L,TO P.L.
PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFU-1-D
SEEPAGE PAGE P�T, DRAINFIELD
OTERRUO—E-E j I P. C. NO,
VXTN.,CESS POOL,DRYWELL,MIAN H 0 LE 2, _cO M.L. NO. j0B NO,
00
HOUSE SEWFR CONNECTING TO
-PRIVATE DISPOSAL SYSTEM s 1.00 1 TRUNK PERMIT NOROAD PERMIT N
CONNECT ADDITIONAL 11.I-D G,UR
STATE ENCROACHMENT
WORK TO 401USE SEWER $I 1 0 0 1 PERMIT NO.
ALTER,REPAIR ORA�3ANDON HOUSE INDUSTRIAL
SEWER OR WSPOSAL SYSTEM 1.
WASTE APPROVAL
e, CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE APPROVALS DATE INSPECTOR-S SIGNATURE
HEREIN -NAMED CON-
TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEIVj��, NEW HOUSE SEWER
DAY 0�
SIGtiED THIS CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGE NI____�__ SEPTIC TANK,SEEP,PIT(5)
ADDRESS_ I v
AND/OR DRAINFIELD
1 HEREBY ACKN`0WLEDGE THAT HAVE READ THIS APPLICATION
[LE
iC 7T
TOTAL
AND STATE THAT THE ABOVE IS CORRECT AND TO CESSPOOLD DPYWELL
AGREE COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMB SEVVIERS
ING AND SEWAGE DISPOSAL SYSTEM
I HEREBY CERIIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED 2y L05 ANGELS +' VNTf AND STATE IF DISCONNECT PLUG AND
J
CALIFORNIA OR THAT � V:l THE LEG. OWNER THE
OWNER C� ABANDON HOUSE SEWER
DESCRIBED RESiDENTIALFI!,0PERTY. f BACKFILL SEPTIC TANKS 0
SEEP,PIT($) D cEsspoqs L!
OF PERMITTEE
JOHN A. LAMBIE. COUNTY ItNGINEER VALIDATION ROBERT A. WOOD,CHIEF' PLEIG, INSPECTOR
CASH
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