HomeMy Public PortalAbout5317 PAL MAL AVE_Sewer__ ° °
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II-55 APPLICATION FOR PERMIT 1
5 3 6
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County Of Lae Angeles BUILDING
JOHN A. LAMBIE,COUNTY ENGINEER
m CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR AP LICANT TO FILL IN en0 ST.
LEGAL OWNER
DESCRIPTION LOT NO. MAIL
BLOCK TRACT / I (/ ADDRESS JI /-` '•
NO.OF SLUGS. CITY TEL. NO
SIZE OF LOT NOW ON LOT
OF
USE DI / ��� DISTRICT NO. GROUP MAP
BUILDINGS
BK PG
CONTRACTOR
ADDRESS Ls 3 CONN W TION DATA
EL.N0. O STATIONfllA DEPTH
CITY
3 7b/ . MANHOLE REFERENCE
f�3 / ❑ STATE At2eLOWER
REGISTRATION NO.
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO PE OF CONNECTION LENGTH FROM /
PUBLIC SEWER @ f 3.50 CURB P.L. Y.L.TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELDIdlP.C. NO.
l
EXTN.,CESSPOOL,DRYWELL,MANHOLE f 2.00 CO. IMP.N0. JOB N0.
I HOUSE SEWER CONNECTING TO A/ /z Z_
PRIVATE DISPOSAL SYSTEM Q $1.00 TRUNK PERMIT N0. ROAD PERM IT NO. K Ol
I CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® f 1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM Q $1.00 INDUSTRIAL
WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERNTT s 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'SSIGNAT URE
01
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS— D F 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT .�P H� SEPTICTANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL 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 1 AM THE LEGAL 0 OF THE AS---
DESCRIBED RESIDENTIAL PROP BACKFILL SEPTIC TANKS❑
SEEP.PITS) ❑ CESSPOOLS❑
SIGNATURE
OF PERMITTEE
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATION ROBERT A.WOOD.CHIEF PLBG. INSPECTOR
CK. m. o. cnsx
_,'ir40
3 s S MAY 5 4 A 45:0 M