HomeMy Public PortalAbout5225 PAL MAL AVE_Sewer__ T6A -66
E APPLICATION FOR PERMIT
3!S •9�8�4'1-$5
DIVISION OF BUILDING AND SAFETY SEWER---SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS ✓
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
_ FOR APPLICANT TO FILL IN doss
IST
—LEGAL — �—
DESCRIPTION LOT NO, -- - OWNER
MAIL
BLOCK TRACT ,.•�ty'.�j'b ..,"++ .. ADDRESS _._ 6> --
i10,OF BLDGS
_SIZE.OF LOT d �-111:'.`NOW ON CGT CITY �� a�.,� TET. N0. �-tee, _V1 y� r'
USE OF DISTRICT NO.V d.P.GROUP MAP
BU[LplNGS_�� i.�_ ._
= BK PG
CONTRACTOR
ADDRESS CONNECTION DATA� �.� -- ---��.- -- -------
STATION DEPTH
_CITY L. NO
MANHOLE REFERENCE
_ 4FW_1R'R:K�
STATE LOWERREGISTRATION NO.. ❑ COUNTY �� iNO, I DESCRIPTIONFEE —_ --
I- TYPE.OF CONNECTION LENGTH FROM
I- HOUSE SFNER CONNECTING TO'--^^ ----i- ----- Y _ CURB P.L. M.L.TO P.L.
_
PUBLIC SEWER __ L; '%3.51� -- ---
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAfNFIELD _ (i' $3.00 j _ -
-� OVERFLOW SEEPAGE PIT,DRAINFIELD � —^^ P. C. NO. -
FXTN.,CESSPOOL,DRYWE'LL,MA.NHOLE. (It $2._001 CO. IMP. NO. JOB NO.
__IHOUSE SEWER CONNECTING TO T ��
PRIVATE DISPOSAL SYSTEM - <ui $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.(DR - f STATE ENCROACHMENT
WORK TO HOUSE SEWER Gcy �1.00 �__� �- PERMIT N0. ----- _` "-----^J`------
ALTER;REPAIR OR ABANDON HOUSE .-
SGA'ER OR DISPOSAL SYSTEM �c $1.00 INDUSTRIAL
--�—-`---- --. ..--' - -- --- ----_ __-_.. :.------------- WASTE APPROVAL
CHARGES
I CONNECTION CHARGE FEE
OWNERS PERMIT _--
AUTHO3RIZATION TOTAL FEE REIMBURSEMENT FEE
__..__—APPROVALS ...i.-_DATE
--- INSPECTOR SIGNATURE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNEC_T,THE ABOVE DESCRR#ED EXISTING DWELLING I -
TO THE PUBLIC ScyM1R ;t 4 NFW HOUSE SEWER
SIGNED THIS DAY OF_ ]S- CONNECT ADDITIONAL
OWNER OR .,• i 1¢ ° BUILDING OR WORK
OWNERS GENT plL :t_ __ re � . - _—
..w SEPTIC TANK,SEEP PIT(S) f
ADDRESS '`: •'I� I�_;"{ L` y.,A e'A,S. `y.s� AND/OR DR AI N F I E LD.�—, _-�_. ....___
-.._. v ----CA - _- - _ -----
1 HEREBY ACKNOWLEDGE THAT I HAVE READ T�S APPLIlON CESSPOOL I_1 DRYWELL L7 I (.
AND STAT 1H ,1 THE ABOVE IS CORRECT AND AGREE TO COMPLY _ ._.-- --.-_-..__._.._..-1-.-�___.,. .--`-�---
i`:IT1$ ALL COUNTY ORDINANCES AND STATE LAWS REGULAT!NG ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SUWAGE D ISPOSAL SYSTEM.
E .F'Y THAT I AM PROPERLY REGISTERED _ NNEC
AND/OR DISCONNECTPLUGANb I
DESCRIBED RES DcN71Fj1w,PRO.PE.RTY-0 D STA`B OF ABANDON HOUSE SEWER ! i
CALIFORNIA OF THAT I AM THE L. OWNEF3,•OF THE AGOVS. _.. _. .:_.- ,__. ._-__.-_---
LICENSEDi AS REQUIRED 3Y LOS ANGELES OtJNTY AN BACKFILL L SEPTIC TANKS r' � j
SiGI`IATUPE SELF. PIT iS) D CESSPOO r..
OF PERMITTEE
1 j
JOHN A. LAMBIE, Cou TY ENGINEER VALIDATION,, ROBERT' A. WOOD, CHIEF PLE3G. INSPECTOR
Q yLA'H
t3I, to as TK l ..1''}
.. 4 4