HomeMy Public PortalAbout5503 PAL MAL AVE_Sewer__ li CE80B9 62
76T662D APPLICATION FOR PERMIT (�1
11
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL 1EE1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING
IOWA
LAMBIE. County Engineer ADURESE
WILL A. IENSEN. Sup't of Building
LOCALITY
NEAREST
FOR P TO L `ROBS ST'
:OF
DN LOT NO. OWNER
MAIL
BTRACT ADDRESS
NO. OF SLOGS. I
ST NOW ON LOT CITY TEL. NO.UDISTRICT NO. GROUP MqP PROCESSED BY
B
C�/ BK PG
CONTRACTOR
ADDRESS CONNECTION DATA
722 1STATION O DEPTH
CITY
L. NO. R
flEGISTRATION NO. LJ COUNTY MANHOLE REFERENCE OW
NO, DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENOTHFROM
MOUSE SEWER CONNECTING TO Y. CURB M.L.TO P.L.
PUBLIC SEWER 0 85.00
SEPTIC TANK.SEEPAGE PIT ON - P.C.NO.
PITS ANO/OR GRAINFIELD 0 810.00 CO.IMP.NO. JOB NO.
HOUSE SEWER CONNECTI NO TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM Q 88.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAII99 I rAMINgIn RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER ! $8.00
OVERFLOW SEEPAGE PIT,GRAINFIELD
E%TN..CESSPOOL.ORYWELL,MANHOLE 0 E5.00
ALTER.REPAIR OR ABANDON HOUSE NWY.OR BT.WJOENING
SEWER OR DISPOSAL SYSTEM _ �_ SS.Do STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
r1RACTOR
WNER'S PERMIT s z o0
CONNECTION CHARGE FEE
HORIZATION TOTAL FEE
E AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
UB CONNECT THE ABOVE DIE IBED EXISTING APPROVALS
E PUBLIC SEW DATE INSPECTOR'S 6IGNATURE
ED THIS�Y OF 19OF 19 R OR NEW HOUSE SEWER
RS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
SS SEPTIC TANK,SEEP.PITIS)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ARD/OR ORAINFIELO
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO OISCON NECT PLUG AND
RESIDE IN. THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON XOUBE SEWEfl
SIGGFATRMITTEE URE BACKFILLSEPTIC TANKS ❑
BEEP.PIT 18) ❑ CESSPOOLS ❑
III _ VMMATIO ROBERT A. WOOD
CK. M.0. CABX SUPERVISING MECHANICAL ENGINEER
i.I„ 09 9 6 6f2 JAN22 1 0 0 7.00"