HomeMy Public PortalAbout5445 PAL MAL AVE_Sewer__11
fiA692O APPLICATION FOR PERMIT 1
6&E-663 1254
DIVISION O£ BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Loa Angeles BUILDING
WM. J. FOX. COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN. SUPT aF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEOSS SARES
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LEGAL77 ef T .�
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DESCRIPTION LOT NO. • ����� OWNER
BLOCK TRACT MAIL
ADDRESS
NO. OF BLDGS, p
SIZE OF LOT NOW ON.LOT +C.. CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP
CONTRACTOR ^ BK PG
ADDRESS CONNECTION DATA
CITY TEL. NO. STATION � DEPTH ts�t s G
❑ STATE /� MANHOLE REFERENCE
REGISTRATION NO. El COUNTY _ & 'J UPPER L�
YPE OF CONNECTION LENGTH FROM
NO. DESCRIPTION OF WORK FEE Lmw- P L M.L. TO P L J O
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q S 3.50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 _
CONNECT ADDITIONAL BLDG. OR CO. IMP. NO. /�p� JOB. NO.
WORK C HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING
_ SEWER OR DISPOSAL SYSTEM 1100 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1,00 STATE ENCROACHMENT
PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2100 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2100 CHARGES
PERMIT CONNECTION CHARGE FEE
OWNER'S s & 00
AUTHORIZATION TOTAL FEE O REIMDURSEIIENT FEE
TRACTORIHAVET HIS TO CONNECTDATEO THE ABOVEWITH DESCR BED EXIISTINGTHE HEREINAMED DWELLING APPROVALS 0 TE INSPECTOR'S 51 NATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT _BUILDING OR WORK
SEPTIC TANK. SEEP, PITS)
ADDRESS - _AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL Cl 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
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. - BACKFILL SEPTIC TANKS❑
SEEP. PITS) ❑ CESSPOOLS
SIGNATURE
OF PERMITTEE
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WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
BY Co1 qY4 7 ; MIAR16 4 650 n
DEPUTY . - DEPUTY
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BY BY
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