HomeMy Public PortalAbout5320 PAL MAL AVE_Sewer__ 24650 INSERTS r
76A642�6U APPLICATION FOR PERM 1
�snsazo COUNTY OF LOS ANGELES �Y�Y
SEWER-SE AGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS J'3 O-
IOHN A. LAMBIE. Countp Engineer
WILLIAM A. IENSEN. Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN cx.SS ST. 'a r/G T"
LEGAL
DESCRIPTION LOT NO. OWNER !�`
MAIL
BLOCK TRACT
�� ADD
N0. F BLDGS.
SIZE F LOT NOW ON LOT CITY TEL. N0.
USE D[ G' DISTRICT NO. GROUP MAP PROCES T
BUILDINGS
L / BK PG
CONTRACTOR �.I`J
ADDRESS �• CONNECTION DATA
CITY TEL.N STATION DEPTH
SPATE MANHOLE REFERENCE UPPER
REGISTRATION NO. COUNTY LOWER
NO. DESCRIPTION WOR FEE
PUBLICSEWER
SEWERCONNECTING TO CO $3.00
SEPTIC T//�NK,SEEPAGE PIT OR Y TYPE OF CURB ECTIONP.L. M.L.TO FROM
PITS AND/OR DRAINFIELD @ S3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD I T
EXTN..CESSPOOL DRYWELL @ Sz.00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ SI.00 I N0. JOB S.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. U
WORK TO HOUSE SEWER @ SI.00 �7
SEWER,O EDAIR OR ABANDON HOUSE @ $1 00 STATE ENCROACHMENT
G
PERMIT N0. O
INDUSTRIAL V
WASTE APPROVAL a
CHARGES
OWNER'S PERMIT j 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT DATE ATHE HEEINED CON.
TRACTOR TO CIONNECT THE ABOVCT DESCRIBED EXISTING ADWELLIING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DA OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR GRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY OR NANCES AND STATE LAWS REGULATING ALTER.REPAIR,SEWER OR
PLUMBING AND SEWE SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIF HAT I AN P PERLY RE ISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REO BY LOS AN S COU Y AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR AM THE L 0 R F THE ABOVE
DESCRIBED REST Y. BAGKFI LLSEPTIC TAN KS ❑
SIGNATURE SEEP.PITS CESSPOOLS
OF PERMITTE
®F VALI ROBERT A. WOOD
c6. •..0.o. GASH SUPERVISING MECHANICAL ENGINEER
I, j.