HomeMy Public PortalAbout5324 PAL MAL AVE_Sewer__ :a[ll3lJ 55 APPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Dopmlment of Coonly Imglaaas
County of Lvs A sz ADOILIN
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JOHN A LAMBIE CouNTv ENGINEER
m CASSATTD GRIFFIN SUPTOPBUILDING LOCALITY L C; ITY
FOR APPLICANT TO FILL INaos"s'TBT i= vas
LEGAL 9
DESCRIPTION LOT NO OWNER
BLOCK TRACT /^� MAILIt
I I L ADDRESS
NO OF BLDO9 CITY NO
SIZE OF LOT B NOW ON LOT
USE OF DISTRICT NO GROU YAP
BUILDINGS
CONTRACTOR
S R P
CONNECTION DATA
ADDRESS
CITY
STATION Z� DEPTH 0
T
MANHOLE REFERENCE O
REGISTRATION N s � ❑Q CSTAT
NTY LOW
E
NO DESCRIPTION OF WORK r FEE
HOUSE SEWER CONNECTING TOTYPE OF CONMECTIO LENGTH FROM
PUBLIC HEWER @ S 3 50 Y CURB Y L TOP L
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® $3 00
OVERFLOW SEEPAGE PIT ORA IN FI ELI P C NO
EXTX CESSPOOL,DRYWELL MANHOLE ® S,
00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® S 1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO NOUSE SEWER Q S 1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® 1 0o WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS PERMCf S 1 1 00
AUTHORIZATION TQTAL Ply REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN M EO CON- APPROVALS DATE INSPECTOR SSIGNATU E
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK SEEP,PIT(S)
ADDRESS ♦ AMD/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL0
AND STATE THAT THE ASOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWEROR
PLUMBING AND SEWER! SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON ROUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGA OWNER OF THE ABOVE
DESCRIBED RESIDENTIA OPERTY BACKFILL SEPTIC TANKS
SIGNATURESEEP PIT(9) CElSPO LS
OF PERMITTEE
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JOHN A LAMBIE COUNTI ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
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