HomeMy Public PortalAbout5552 PAL MAL AVE_Sewer__ CCBOBJ °' APPLICATION FOR PERMIt
TeweAEo COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
BUILDING AND SAFETY DIVISION 9EA
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AL D[BCRIPiION LOT NO (T
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SIZE OF LOT ITY TEL NO
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CONTRACTOR �) n i
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STATE C� UPRR
REGISTRATION NO COUNTY MANHOLI REFERENCE
NO DESCRIPTION OF E[ TYPE or CORRECTION NOTH FR
HOUOQ S[W!R CONNICTINO TO ^ /}/1 CURS P L ML TOIL
PUBLIC SEWER fe OO V(/
SEPTIC TANK SEEPAGE PIT OR / JO NO V
PITS AND/OR DRAINFI[LO Q [1000 GO IN NO JOB NO
HOUR!{EWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO �
PRIVATE DISPOSAL SYSTEM Sam
CONNECT ADO ITIONAL BLDG OR AFFIDAVIT ReMv [uu(IM RECORD INSTR NO OAT[
WORK TO HOU BE SEWER C Sam
OVERFLOW{[SPAGS PIT GRAINFIELD
EKTN CESSPOOL DRYWELL MANHOLE O [S 00
ALTER REPAIR OR ABANDON HOUSE HWY ORST WIDENING
SEWER OR DISPOSAL SYSTEM Q [800 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OYINW S CHARGES
PERNt!'[ s z o0
AUTHOFMTION TOTAL FEF CONNECTION CHARD[F[[
1 HAVE AT THIS DAT[ A CONTRACT WITH THE ME"[IN MQD COM RQIMSURSEM[NT FEE
TRACTOR TO CONNECT THE ABOVE D[{CRIBID "I"INO DWELLING AI'C80VAL3
TO THE PU RLIC SEWER DAT[ INSPECTOR S SIGNATURE
SIGNED TH I6 DAY OF 10_
OWNER OR N[W HOUSE SEWER
OWNERS AGENT CORRECT ADDITIONAL
ADDRESS BUILDING OR WORK U If
SEPTIC TANK eleP PIT(S)
I HEREBY ACKNOWLEDGE THAT IL
D THIS APPLICATION AND/OR DRA I NFIELD
AND STATE THAT THE ABOVE IS CAND AORE! TO COMPLY
WITH ALL COUNTY ORDINANCES LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1HERESY CERTIFY THAT IAM EGISTERED AND/OR ALTER REPAIR {EWER OR
LICENSED AS REQUIRED BY LOS ANTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM TX[ LEOF AND INTEND TO ONNECT PLUG AND
RESIDE IN TIQ ABOVE OE°CRIBCDL OPIRTY ABANDON HOUSE BOWER
SIGNATURE
OF PERM ITT BACKFILL SEPTIC TANKS
❑
S[OF IT(S) ❑ CE{SPOOIA
VALIDATION ROBERT A WOOD
cK M o ueH SUPERVISING MECHANICAL ENGINEER
LAo268leo WR2910 D 7.00" Q
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