HomeMy Public PortalAbout5546 PAL MAL AVE_Sewer__ CE00B8-80 APPLICATION FOR PERMIT
)6A642D COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSIONAMIBUILDING
ADDRESS
10MN A. . JENSE, CouutI Ea�1nee)
WILLIAM A. IENSEN, Supt of Buildiv4 LOCALITY
NEAREST
FOR APPIdCANjT0 W INcnoss sr.
LEGALnp '' OWNER F
DESCRIPTION LOTNO.
BLOCK TRACT MAIL
ADDRESS
NO.OF SLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP I ESSED BY
BUILDINGS
BK PG
CONTRACTOR �� Y �.
Jv
ADDRESS v _ U CON14ECTION DATA'-/4
CI TEL.NO.,Fl)_ Q ATION DEPTH
I IV STATE MANHOLE REFERENCE
REGISTRATION NO. COUNTY IOW ER
NO. I DESCRIPT10m UF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONN C N LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. R P.L.' M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EKTN_CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT N0. O
V
ALTER.REPAIR ON ABANDON HOUSE STATE ENCROACHMENT 04
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO. 0
INDUSTRIAL
WASTE APPROVAL WM
CHARGES
OWNERS PERM 3 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE /p REIMBURSEMENT FEE
I HAVE TRACTOR TO CIS DATE A CONTRACT WITH THE ONNECT THE ABOVE DESCRIBED EXISTIINGAME CON.
DWELLING APPROVALS DATE INSPECTORS SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER '
OWNER OR CONNECT ADDITIONAL
OWNERSAGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PITS)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT IHAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
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 DISCONNECT PLUG AND
LICENSED AS REOUIRE0 LOS ApSELES COUNTY NO STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT M TH LEGAL OWNE F THE ABOVE
DESCRIBED REST NT ROP BACKFILL(EP IC CEN P00❑LS ❑
SIGNATURE
OF PERMITTE '.>
®� ALIDATION ROBERT A. WOOD
CG
RIO. CASH SUPERVISING MECHANICAL ENGINEER
},`', 6 OCT 3 1 _ r
CEB08 5-60
APP (CATION FOR PERMIT
JBAe°'D COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING
ADDRESS
IOHN A. LAMBIE, Countp Eagineex
WILLIAM A. JENSEN, Bup't of Building LOCALITY
NEAREST
FOR APPLICANTJO IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. L OWNER
BLOCK TRACT MAIL
ADDRESS
N0.OF BLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BDINGS
DISTRICT NO. GROUP HK MAP PG I PROCESSED BY
UIL
CONTRACTOR U V
ADDRESS CO C O DATA
CI TEL.N0. ATION DEPTH
REGISTRATION NO.
STATE MANHOLE REFERENCE
COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER
WR
EECONNECTING TOPUBLI@ S3.00
TYPE OF CONNECT N LENGTH FROM
SEPTIC TANK.SEEPAGE PIT OR Y. Cup P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ S3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD ("
E%TN..CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. N0. JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0. G
WORK TO HOUSE SEWER @ St.00 0
ILI
ALTER EP I ABANDON HOUSE STATE ENCROACHMENT W
SEWE R L SYSTEM @ $1.00 PERMIT NO. 0
INDUSTRIAL F'
WASTE APPROVAL W
CHARGES vai
OWNERS PERMIT E CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE TRACTOR TO CIS
ONNECT THE ABOVE DESCRIBED EXISTING DWELLNAMED ING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. -
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS AND/ORSEPTIC TANK,SEEP.DRAINFIELD
IT(B)
1 XEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING ANO SEWEftS. SEW AGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PR PERLY REGISTERED AND/OR bISCONNECT PLUG AND
LICENSED AG REOVIRED LOS AN LES COUNTY STATE OF pgAN DON HOUSE SEWER
CALIFORNIA OR THAT THE GAL OWNER F THE ABOVE
DESCRIBED RESID Ti OPER BACKFILL SEPi1C TANKS ❑
SIGNATURE S P. PIT(S) ❑ CES PO 5 ❑
OF PE MITTE
®Y ALIDATION ROBERT A. WOOD
M.o. OAgM SUPERVISING MECHANICAL ENGINEER
-_ U C
J .� OCT :� 1
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