HomeMy Public PortalAbout5325 PAL MAL AVE_Sewer__ TaA°'R° APPLICATION FOR PERMIT 1
aaRRRDIVISION OF B=ING AND SAFETY SEWER-SEWAGE DISPOSAL
Dapmt n*w of County Enpinaar
County °' �' A"Q'u' ADL 1111' "32 --27-31 Nl Pa
JOHN A LAMBIE CouNTY ENGINEER aSS
m CASSATTD GRIFFIN SUPTOPOUILDIXa LOCALITY
EST
FOR APPLICANT TO FILL IN CROSS ST •✓ tpvd
LEGAL 1CO�
DESCRIPTIONLOT NO OWNER l
BLOCK TRACT PAIL
Q ADDRED!
NO OF BLDG
SIZE OF L 0 MOW ON LOT CIT' TEL NO
USE OF DISTRICT NO GROUP YAP
BUILDINGS 'Pi
S. R PG
CONTRACTOR .i //
ADDRESS CONNECTION DATA
STATION DEPTH
CITY TEL 0
MANHOLE REFERENCE-
❑ STATE S L
REGISTRATION NO ZZ ❑ COUNTY
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF COMNECTIO LENGTH FROM �S 1
PUBLIC SEWER @ S 3 SO Y CURB P L Y L TO P L /Z
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR GRAINFIELD 0 S 3 00
OVERFLOW SEEPAGE PIT DRAINFIELDP C NO
EKTN CESSPOOL DRYWELL MANHOLE® $2 00 CO IMP NO JOB M°
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® $10o TRUNK PERMIT NO ROAD PERMIT NO
CON N ECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® S 100 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® 1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS PEST $ 1 00
AUTHORIZATION I TOTAL PEP O REIMBURSEMENT FEE
I HAVE AT THIS TE A CONTRACT WITH THE HEREIN HAYED COM APPROVALS DATE INSPECTOR !SIGNATURE
TRACTOR TO CO CT E B E DESCRIBED EAIST NG DWELLING
TO THE PUBLIC ER NEW HOUSE SEWER i .s
SIGNED THI COM NEU ADDITIONAL
OWNER O0. BUILDING OR WORK
OWNERS AGENT BEPTICTANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT Ill EA0 THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THEABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNT ORDINANCES AND STATE LAWS REGUI,ATING ALTER,REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT AY PROPERLY REGISTERED ND/OR DISCONNECT PLUG AND
LIC LASED A3 REQUIRED BY L03 ANGELES CO TY AND TE OF
Cj<rFORNjA OR THAT I Y THE LEGAL OW EA F TH ABOVE ABANDON HOUSE SEWER
SCRIBE ESIDENTIALP P TY BACKFILL SEPTIC TANKS❑
B U SEEP PIT(S) ❑ CESSPOOLS
P VITT Y
JOHN A LA IE COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CK Y 0 AFN
4 7 9 3DEC 3 4 650 �