HomeMy Public PortalAbout5415 PAL MAL AVE_Sewer__ CCmeom °' APPLICATION FOR PERMIT
AUIO D
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
MAMIENT OF COUNTY ENGINEER
SUHMING AND SAFETY DMSION SUILoIna
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LEGAL,
DESCRIPTIN LOT NO OWNER
MAIL
[LOCK TRACT O ADDRESS
NO OF SLDOS
SIZE OF LOT NOW ON LOT CITY TEL NO
UBE OF /w DISTRICT NO GROUP MAP PROCESSED BY
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BN PO -714
CONTRACTOR �
ADDRESS D S 7 CONNECTION DATA
CITY � TEL No Cp6e L O STATION DEPTH
�j �j STATE MANHOLE REFERENCE UPPER
REGISTRATION NO V G / COUNTY LOWER
No DESCRIPTION OF W RK F[[ TYPE OF CONNECTION LENGTH FROM O
HOUSE SEWER CONNECTING TO V CURS P L M L TO P L V
PUBLIC SEWER 0 $500
SEPTIC TANK SEEPAGE PIT OR J C NO Oj
PITS AND/OR CO GRAINFIELD 0 t10 DO
CO IMP NO JOS NO O
HOUSE DISPOSAL
CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO V44ryl[
PRIVATE DISPOSAL SYSTEM Q t]00 4
CONNECT ADDITIONAL SLOG OR r
FIDAVIT PYY[[ u[[Y[NT RECORD INSTR NO DAT[
WORK TO HODS[{EWER 0 1300Clio
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OVERFLOW SEEPAGE PIT GRAINFIELD L
[XTN CESSPOOL ORYWELL MANHOLE 0 tS GO
ALTER REPAIR OR ABANDON HOUSE Y OR ST WIDENING
SEWER OR DISPOSAL SYSTEM 0 1300 T[ENCROACHMENT
RMIT NO
INDUSTRIAL • O
ST[APPROVALCHARGtBOWNERS FERMT s 2AUTHORIZATION TOTAL FEL' NNECTION CHARGE FEEIHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMEDIMBURSEMENT FECTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWwnO�TO THE PUBLIC SEWER AP DATE INSPECTOR S SIGNATURE
SIGNED THIS DAV OF OWNEROR W HOUSE SEWER A JAOWNERS AGENT NNECT ADDITIONAL [[ILDIN00R WORK T/ADORES{ PTICTANK S[[P PITIS)IHEREBY ACKNOWLEDGE THAT 1 HAV[ READ THIS APPLID/OR GRAINFIELDAND STATE THAT THE ABOVE li CORRECTAND AGREE TOCWITHALL COUNTY ORDINANCES AND 'TATE LAWS REGULPLU MS INO AND SEWERS POOL ❑ ORYW[LL ❑
I HERESY CERTIFY THAT I AM PROPERLY REGISTERED AMO/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STAT[ OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND IHT[HD TO DISCONNECT PLUG AND
RESIDE IN TH[ ABOVE CRIB[D RESIDENTIAL PROFERTY ABANDON HOUSE SEWER
SIGNATURE
OF FERMITTEQ iECKFILI SGPT G TANKS
iCV PRIS) CESSPOOLS
VALIDATION ROBERT A WOOD
CK M D CAB. SUPERVISING MECHANICAL ENGINEER
I -r'0 4 1 5 3 e JAN 7 1 0 A 5.00-
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