HomeMy Public PortalAbout5623 PAL MAL AVE_Sewer__ o:a Ci 1188 APPLICATION FOR PERMIT 1
DIVISION OF BUMDING AND SAFETY SEWER—SEWAGE DISPOSAL
DGro>Ittnont of County Engineer
County of Los Angolss BUILDING // q�V
JOHN A LJAMBIE COUNTY ENGINEER ADORES! Old
m CASSATT D GRIFFIN SUP TOP BUILDING LOCALITY
�'p,�, NEAREST
FOR PLIC_AIjT TO i � f CROSS ST
LEGAL -5O
DESCRIPTION L071,10 OWNER ��0
■AIL f
BLOCK TRACT S/z Z ADDRESS tl
SIZE OF LOT NOW0717x f
NO OON LOTS /-4— CITY TEL NO
USE OF DISTRICT NO GROUP YAP `
BUILDIN63 �'
S .� BK PG
CONTRACTOR S
ADDRESS CONNECTION DATA
STATION DEPTH '
CITY TEL NO UPPER
MANHOLE REFERENCE
❑ STATE LOWER
REGISTRATION NO ❑ COUNTY _
No DESCRIPTION OF WORK FEE
ROUSE SEWER CONNECTING TOTYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ $3 SO T RB P L Y L TO P L
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® S S 00
OVERFLOW SEEPAGE PIT DRAINFIELD C NO
QTN CESSPOOL DRYWELL MANHOLE 2 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® S 1 00 TRUNK PERMIT NO,,----
O ROA RYIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROA ENT
WORK TO HOUSE!EWER ® S 100 PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE INDUSTR
SEWER OR DISPOSAL SYSTEM S 1 OD WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS PEUMT s 1 00
AUTHORIZATION TOTAL FEE G REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED COM APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY OF 19— CONNECT ADDITIONAL IL.,
OWNER OR BUILDING OR WORK J'F
OWNER! AGENT SEPTICTANK SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND 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 DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AY PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AN THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE
SEEP PITS) [1 CESSPOOLS[IOF PERMITTEE
JOHN A LIAMBIE. COUNTY ENGINEER . ALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
M5 3VR" Mth20 sR 4 200 m