HomeMy Public PortalAbout5614 PAL MAL AVE_Sewer__ � ZP s.e-o'
fuaAAq, APPLICATION FOR PERMIT
�- COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGOMM
BUILDING AND SAFETY DIVISION BUILDING
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STATE MANHOLE REFERENCE UPPER
REGISTRATION NO COUNTY LOWER
no I DSERI T N W K FEE 8 o 8R
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TYPE T^NK SEEPAGE PIT OR PE OF CONNECTION LENGTH FROM
PITS AND/OR DRAINFIELD T CURB P L ■LTO!L
OVERFLOW SEEPAGE PIT DRAINFIELD
N CESlPOOL DRYWE 300
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PR D P 0 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER0 111 00
A TER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
G[SPOAL N 100 PERMIT NO
IRDUSTRIAL
WASTE APPROVA
11 CHARGES
OWNER'S FERM T 2 00 CONNECTION CHARGE FEE
AUMOFMnON I TOTAL FEE REIMBURSEMENT FEE
CON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED U IISTDAA CNTRACT WITH THE IINGAMED DWELLIN6 APPROVMS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 18_ NEW HOUSE SEWER
OWNER OR COXMECT ADDITIONAL
OWNERS AGENT �l4r� BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PITS)
AMD/OR GRAINFIELD
1 HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION
ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL DRY-WELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWEROR
PLUMBING AND SENERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AN 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 Ot if WN OF THE ABOVE
DESCRIBED RESIDEM ROP TY BACKFILL SE IC TANKS
SIGNATURE SEEP PT
3 CESSPOOLS _
OF PERM
m' AIMATION ROBERT A WOOD
CL ■ 0 GSM SUPERVISING MBCNANICAL YNGINMM
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