HomeMy Public PortalAbout5544 PAL MAL AVE_Sewer__ t
TffA 1A2D - crepe - 9/73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
5544 N . Pal Mal
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MC„O[ NO, 316018 A.C36 &2o MANHOLE REFERENCE UPPER,
No DESCRIPTION OF WORK I[[ TYM,oPCOMMECTION LENGTH FROM
NOUS[SEWER CONM[CTIMO TO Y CURB R L ML TOP L
IUBLIC S[W[R O :T 00 #f4 'C NO
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'ITS AND/OR°RAINFIEL° O stow G01"P NO
NOUS{S[WZR CONNECTING TO TRUNK PERMIT NO ROAD PERMIT ND
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CONN CT ADDITIONAL AFFIDAVIT FMAI lulElRf RECORD INBTR NO DATE
WORK TO HOUSESEWER O OO
OVERFLOW SEE FAUK'IT DRAI"II[LD
EETN CESSPOOL DRYWELL O ES W HWY OR WIDENING
ALTER R A ABANDON OZ
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MANHOLE O $T 00 PERMIT NO W
INDUSTRIAL
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COHN[CTIOM CHARGE FEE
AUTHORIZATION TOTAL PEE
I HAVE AT THIS DAT( A CONTRACT WITH THE "(REIN NAMED COR REIMMURSEMERT ME
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING AMOVAI�
TO CTHETO PTO C SEWER DAT[ INSI[CTOR SSIOMATYR[
SIGNED THIS DAY OF IB_
OWNER OR NEW KOU•[SEWER
OW"[RS AGENT CORRECT ADDITIONAL
ADDRESS BUILDING ON WOR" �Q
SEPTIC TANK BEEF PIT(G)
1 HERESY ACRNOWL[°°[ THAT 1 "AVE READ THIS APPLICATION AN°/OR DRAINIIELD
AND STATE THAT THE ABOVE IB CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANC[e AND STATE LAWS RROULATINO
FLUMB[NO AND SEWERS CESSPOOL ❑ ORYW(LL ❑
1 HEREDY CERTIFY TNAT I PROPERLY RE°IST(RE° AMO/OR ALTER REPAIR SIW[R OR
LICENSED AB RIOUIR(D pV A"OL[S COUNTY AM° STATE OF B[WAO[DISPOSAL SYSTEM
CALI/OMNIA OR TNAT 1 AM E L[°AL WN[R OI AND INTEND TO DIBCONN[CT FLUO AND
RESIDE IN TH[ ABOVE ° RIeE° MTIAL MOF[RTY ABANDON HWS[SEWER
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COUNTY OF LOS APPLECATION F SEWERRSE AGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FAD015's
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Supt of Building FOR APPLICANT; TO LL IN .LEGAL DESCRIPTION LOT N0. fiBLOCK TRACT
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON OT CITY TEL. NO.
USE OF DISTRICT N0. GROUP I MAP I PROCESSED BY
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ADDRESS ONNECTION DATA
CIT EL.NO. _ ATION DEPTH _
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• STATE MANHOLE REFERENCE `
REGISTRATION NO. n(/.J ❑ COUNTY Y l LOWER
NO. DESCRIPTION OF WORK FEE - —
HOUSE SEWER CONNECTING TO �' � /✓ ' C-. -. '
PUBLIC SEWER @ $3,00 TYPE OF CONN a' LENGTH FROM �7
SEPTIC TANK.SEEPAGE PIT ORY. C P.L. M.L.TO P.L. ..L
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EKTN..CESSPOOL. DRYWELL @ $2.00 P,C.NO.
HOUSE SEWER CONNECTING TO "� -
PRIVATE DISPOSAL SYSTEM IS, SI.00 CO.IMP. N0. JOB N0.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER $1.00 THUNK PERMIT N0. ROAD PERMIT N0. O
@ O
SEWER OR UASPOSHLABANDON SYSTEM HOUSE @ $100 STATE ENCROACHMENT Pf
PERMIT NO. O
INDUSTRIAL U
WASTE APPROVAL W
CHARGES
OWNER'S PERMIT S Z UD CONNECTION CHARGE FEE
AUTHORIZATION FTOTAL FEE VL' REIMBURSEMENT FEE
CON-
TRACTOR TO CIONNECT THE ABOVE EDATE A CONTRACTIS RIBED EXIISTINGTHE HEREINAMED DWELLIING APPROVAIS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19 NEW HOUSE SEWER --Y
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUI LDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PITIS)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL 0
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING p LT ER.REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED B OS ANG ES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I A THE GAL HER OF E ABOVE
DESCRIBED RESIDENT" OPER BACKFILL SEPTIC TANKS ❑
SIGNATURE
SEEP, IT(S) Cl CESSP OLS El F
OF PERMITTE
®r �j.ILIDA ON ROBERT A. WO D
_ ca Y D cAgM SUPERVISING MECHANICAL ENGINEER
J OCT 3 1 1 U .i
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. APPLICATION FOR P RMIT ,
COUNTT OF LOS ANG ELFS SEWER—SEWAGE DISPOSAL 1
DEPARTmmT OF COUNTY ENGuMM
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BUILDING AND SAFETY DIVISION ADORE"
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FOR APPLIC T IN CROSS BY
LEGAL
DESCRIPTION LOT NO 7WIIEII
BLOCK TRACT MAIL
ADDRESS
No OF BLDG9
SIZE OF LOT NOW ON LOT TTY TEL NO
USE OF DISTRICT NO GROUP YAP PROCfiDDEO BY
BUILDINGS
B6 PG
CONTRACTOR114,
ADDRESS ` _CONNECTION DATA
C TEL NO —O lox DEPTM
ATE MANHOLEREFERENCE
REGISTRATION NO COUNTY
No ppD9Eg DESCRIPTION R FEE
PIOIBLICSSENERCONNECTING TO !00
SEPTICTA NK SEEPAGE PITOR T TYPE OF PUREE P L MEMr
L TOHPFROY
PITS AND/OR DMINFIELD 33 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EKTN CE33 L D 1 00
HOUSEHOUSE SEWER CON NECT ING TO P C NO
1 PO''SS(AL11S�Y 100 CO IMP NO JOB NO
WORK TO XODUSEI9EW E0.LOG OR TRUNK PERMIT NO ROAD PERMIT NO
A EPAIR OR APo ALBANDONSYSTEM HOUSE l STATE ENCROACHMENTPERMIM
INDU IA p
INDUSTRIAL
WASTE APPROVAL
CHARGES
O{�TIQM•s PEBMT CONNECTION CHARGE FB[
AUTHORTLATION TOTAL FEE RE YBURSEY[NT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EZISTINO DWELLING APPROVALS DATE INSPECTOR D716NATURE
TO THE PUBLIC SEWER
SIGNED THIS SAY OF +9_ NEW x°uae SEWER I/
OWNER OR CON NECT ADDITIONAL /!w
OWNERS AGENT BUILDING OR WORK 1✓
ADDRESS SEPTIC TANK SEEP PIT(8) 1 \/
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION -
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL DRYWELL •1
WITH ALL COUNTT ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS ALTER REPAIR SEWER OR
1 HEREBY CERTIFY THAT A■ PERU REGISTERED AMD/0R SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED OS A LES COUNTY D !TATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT THE GA WHER TX6 ABOYE ABAXDON ROUSE SEWER
DESCRIBED RESI NTI OPE BACKFILL 9E C TANKS LI
SIGNATURE SE PIT E CESSPOO
OF PERMITTE '
mF /-NALIDATION ROBERT A WOOD
CL a ° aK SUPERVISING MECHANICAL MNGINZM
LK,p8191 -� OCT31 11 D 25QO