HomeMy Public PortalAbout5620 PAL MAL AVE_Sewer__ D
$690APPLICATION FOR PERMIT 1
DION OF BUILDING AND SAFt"PY SEWER—SEWAGE DISPOSAL
Deportrnant of Connty En&eer
County of Lw ABgalm BUILDING L
WM J FOX, COUNTY ENGINBBR ADDRESS
CASBATT D GRIFFIN SUP T OF BUILDING LOCALITY7(11
FOR APPLICANT TO FILL IN NEAREST
CROSS ST
LE GA
DES RIPTION LOT NO J OWNER
BLOCK TRACT MAIL
ADDRESS
SIZE OF LOT S �,}� NOWOON LOTF BLDGS o�
CITY TEL NO
USE OF
BUILDINGSLL DISTRICT NO G UP YAP
LB w Pc
CONTRACTOR /A-6 k
ADDRESS $ CONNECTION DATA f
CITY fr TEL NO STATION DEPTH
❑ STATE / d0 1 MA PPER EFERENCE
REGISTRATION NO -3-797I3MPY -
TYPE OF GONNfiCT LENGTH FROM ~7
No DESCRIPTION OF WORK FEE Y cope P L ML TO P L L
HOUSE SEWER CONNECTING TO
PUBLIC SEWER ® f !SO _S�
HOUSE SEWER CONNECTING TO ,
PRIVATE DISPOSAL SYSTEM foo
CONNECT ADDITIONAL SLOG OR CO IMP NO /3 JOB NO
WORK TO HOUSE SEWER 100 L!
ALTER OR REPAIR Er ISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 100 PERMIT NO
SEPTIC TANKSEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL•DRYWELL -- WASTE APPROVAL
SPECIAL CONDITIONS ONLY -zoo CHARGES
PEBMLT CONNECTION CHARGE FEE
QWIIIEB'$ S 7 00
AUMOBMTION TOTAL. FEE � REIMBURSEMENT FEE
TRACTORHAVE TTOS CONNECT THE DATE CTED ABOVE DESCRIBEDWITH THE H EXISTINGEREIN AMED DWELL G APPROVALS DATE INSPECTOR SS1GNATURE
TO THE PUBLIC SEWER A
SIGNED THI DA) OF 19. NEW xousE sfiwEq
OWNEROR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
AOORE36 AND//'ORTA
ORAINFEELDPIT(S)
I HEREBY ACKNOWLEOGC THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL 13AND 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 DISP09AL SYSTEM
I HEREBY CERTIFY THAT I AN PROPERLY REGIST ` AND/
LICENSED AS REQUIRED BY 09 ANGELES COUNTY D STAT DISCONNECT PLUG AND
CALIFORNIA OR THAT i THE LEGAL O Ea NR 0 E ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL iBTY d BACKFILL ifiP C TANK[[[''11 f
SEEP PIT(S) cT SPOOLG
SIGNATURE
OF PERMITTEE d
WILLIAM J F X, umTY ENou mast VALIDATION C��1
AT 3Co4Y$ 6 01A fEB24 4 450 •
DEPUTY DEPUTY
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' ® DEPUTY DEPUTY