HomeMy Public PortalAbout5536 PAL MAL AVE_Sewer__ 76k642° APPLICATION FOR PERMIT 1
feE6DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
WM.J. FOX. COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN, SUPT O F BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST 7
C' S
ST.
LEGA
DESCRIPTION LOT NO. OWNER
_�_,, / �' � MAIL
BLOCK TWR /4 _, �_, �f� y���f ADDRESS J
{ N0.OF BLDGS.
SIZE OF LOT NOW ON LOT 3 CITY TEL.N0.
USE OF
BUILD',GS DISTRICT NO. GROUP MAP
8K PG
CONTRACTOR a r 1
ADDRESS 4/ �` X JtA'C iA . '�•! CONNECTION DATA
CITY ({ TEL. NO,jt STATION DEPTH
ESTATE MANHOLE REFERENCE UPPER
REGISTRATION NO. L ' ' ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE ONNECTION ENGTH FROM
PUBLIC SEWER ® $ 5.50 Y. C a P.L. M.L.TO P.L.HOUSE SEWER CONNECTING
/
PRIVATE DISPOSAL SYSTEM TO 1.00 ( /
CONNECT ADDITIONAL BLDG. OR P. C. NO.
WORK TO HOUSE SEWER 1.00 Q CO. IMP. NO. JOB NO.
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
I AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
I SEPTIC TANK, SEEPAGE PIT OR INDUSTRIAL /
PITS AND/OR DRAINFIELD 2.00 WASTE APPROVAL
CESSPOOL-DRYWELL
SPECIAL CONDITIONS ONLY 2.00 )FHARGES
CONNECTION CHARGE- E
OWNER'S PERMIT s t OD
AUTHORIZATION I TOTAL FEE 'Z e d REIMBURSEMENT FEE
I HAVE TRACTORTO DATE CONNECTOTHEACTED ABOVEWITH THE DESCRIBEDX EXISTINGMED CON.
DWELLING APPROVALS DATE INSPECTORS SIGNATURE
TO THE PUBLIC SEWER �,,,_ NEW ROUSE SEWER
SIGNED THIS DAY OF19
OWNER OR {�'J�.rT_ ' CONNECT ADDITIONAL L
OWNERS AG T;' O.L. �f�'l�[.-IL-k —
AND/OREPTIC T DRAINFEELUPIT(S)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ 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
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AY THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PR TY. BACKFILL SEPTIC TANKS❑
SEEP. PIT(S) CESSPOOLS
SIGNATURE
OF PERMITTEE
WILLIAM J.FOX.Co"Tr Emana .R VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR
C2 27 7— 'Pw37 4 2 . '. r In