HomeMy Public PortalAbout5515 PAL MAL AVE_Sewer__ 7FA642" APPLICATION FOR PERMIT
CE.°° `FC COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRESSG
CASBOHN RAIT D. GRILAIMBFFTEINC SuP pt of Building
LOCALITY
NEAREST
F2A APPLIC T TO FILL4P=�TATE
OSS ST. /
LEGAL / I NER qDESCRIPTION L T 0.BLOCK TRACT yIL _ .'LDRESSNO.OF BLDGS.SIZE OF LOT NOWOLOTTY L L N0.
USE OF A, RICT N0. ROUP MAP P CESSE Y
BUILDINGS 0 ��-4i gosBK PcCONTRA �ADDRESS c'<j4j - CONNECTION DATA
CITY TEL.NION DEPTH
NHOLE REFERENCE PERREGISTRATION NO CS ��N0. DESCRI TIONOF WORK FEEHOUSE SEWER CONNECTING TOPUBLIC SEWER @ SB. TYPE OF CONNECTION LENGTH FROMSEPTIC TANK,SEEPAGE PIT OR CURB P.L. N.L.TO P.L. -36
PITS AND/OR DRAINFIELD @ SS.OVERFLOW SEEPAGE PIT.DRAINFIELDEXTN. CESSPOOLDRYW ELL $2.HOUSE SEWER CONNECTING TO P.B O.PRIVATEDISPOSALSYSTEM $I.0 . IMP. N0. JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0.
WORK TO HOUSE SEWER $1.00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
CFQ INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE 6-0 REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING PROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 1.-, t9— NEW HOUSE SEWER
OWNER OR •�� I,F/ /� S CONNECT ADDITIONAL
OWNERS AGENT j(�I vv „ BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY CESSPOOL ElDRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
ICi HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND ST TE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF TH ABOVE
DESCRIBED RE D L. OPERT ^ BACKFILL SEPTIC TANKS ❑
SIGNATURE r, 5 PILLS ❑ TANKS
OF PER
®' V41A4 xl?�
ALIDATION ROBERT A. WOOD
<K K.0, a K SUPERVISING MECHANICAL ENGINEER
X0582.1$ JM2911 A 25.00 x
CE8088 ' APPLICATION FOR PERMIT
casae a-SP COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING
BUILDING AND SAFETY DIVISION ADDRESS
TOHN A. LAMBIE, County En ser
CASSATT D. GRIFFIN, Suprt of Building IOCALTTr
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.LEGAL
i s
DESCRIPTION LOTN OWNER iT y �T
BLOCK TRACT 'Z fif
NAIL
ADDRESS
N0.OF BLD'S.
SIZE OF LOT NOW ON LOT ElL NO.
USE OFf DISTRICT X0. G OUP P ESSED
BUILDINGS gK PG I
CONTRACTOR J
ADDRESSCONNECTION DATA
CIT Y�a ' TEL " T ION f / DEPTH —
STATE MANHOLE REFERENCEPP
REGISTRATION N0. ff-COUNTY
NO. I DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO _
PUBLIC SEWER to S3.00 TYPE OF CONNECTION LENGTH FROM `
SEPTIC TgMR,SEEPAGE PIT OR Y. CURB P.L. N.L.TO P.L.
o�
PITS AND/OR DRAT NFIELD 55.00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN..CESSPOOL.DRYV/ELL @ $2.00
HOUSE SEWER CONNECTING TO 31 P.C.NO.
PRIVATE DISPOSAL SYSTEM @ 51.00 CO. IMP.N0. 13 JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. f ROAD PERMIT NO.
WORK TO HOUSE SEWER SLOO U
ALTER. R E PAIR OR ABANDON HOUSE STATE ENCROACHMENT
EWER OR D SPOSALSYSTEM
Y T M @ $1.00 PERMIT N0.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 00 REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING PROVALS DATE INSPECTOR'SSIGNATURE
TO THE PUBLIC SEWER
SIGNED THI DAY OF 1 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGEN BUILDING OR WORK
ADORES SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
IM
ACKNOWLEDGE THAT 1 HAVE AD THIS APPLICATION
ANO STATE THAT THE ABOVE IS CORRECT ND AGREE TO COMPLY CESSPOOL 0 DRYWELL
WITH ALL COUNTY ORDINANCES AND VATE LAWS REGULATING A LTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF HE ABOVE BACKFILL SEPTIC TANKS ❑
DESCRIBED RESID IAL�ROPERTY.
SIGNATURE u ,,,Cl S P. PIT(S) 0 CESSPOOL
OF PER
G�1'✓`I
OF VALIDATION ROBERT A. W OD
C M.O. CASH SUPERVISING MECHANICAL ENGINEER
LG582OS JAN 291 0 A 6.00
�i1?16`f 111