HomeMy Public PortalAbout5626 PAL MAL AVE_Sewer__ CRESOS 10-63 0 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
RUD.DING AND SAFETY DIVISION IgA.UNESS
JOHN A LAMBIE County Enn�nDeer
WILLIAM A IENSEN Sup t of Buddmg
LOCALITY T� .Q
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T
GAL 1
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BL OGS
SIZE OF LOT NOW ON LOT CITY VIP,'DIV
r
USE OF TEL NO
BUILDINGS DISTRICT NO I GROUP MAP PROCESSED BY
BK PO
CONTRACTOR
ADDRE65 CONNECTION DATA
CITY TEL NO STATION \ DEPTH
STATE UPPER
REGISTRATION NO COUNTY MANHOLE REFERENCE LOWER
NO DESCRIPTION OF WORK FEE TYP! FCONNECTION L GTH FROM
HOUSE SEWER CONNECTING TO Y CURB PL M L P L 1
PUBLIC SEWER f500
SEPTIC TANK BEEPAGE PIT OR J C NO O
PITS ANO/OR DRAINFIELD ® f1000 LO M NO OB NO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO C
PRIVATE DISPOSAL SYSTEM ® 1300 0
CONNECT ADDITIONAL BLOC OR AFFIDAVIT Ary AUKa RECORD IN9TR NO DATE Vr
WORK TO HOUSE SEWER ® S300
OVERFLOW SEEPAGE PIT DRAINPIELO W
E%TN CESSPOOL DRYWELL MANHOLE o C5 OO CI'
ALTER REPAIR OR ABANDON HOUSE HWY ORST WIDENING w
SEWER OR DISPOSAL SYSTEM ® 1300 STATE ENCROACHMI 2
PERMIT NO
INDLSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s i o0
AUTHORIZATION TOTAL FEE CONN ECTIO HARGE FEE
I HAVE AT.THIS DATE A CONTRACT WITH THE HEREIN NAMED CON BEIM RBEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED E%ISTING DWELLING IGNATURE
APPROVALS
TO THE PUBLIC SEWER DATE IN9PECTORBB
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECTADDITIONAL
ADDRESS SUILDING OR WORK
ND/O
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION ATANK SEEP PIT(S)
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY ANO/OR DRAINFIILO
WITH ALL COUNTY 0ROINAN C ES AND STATE LAWS REGULATING Cl
UMBI NO AND SEWERS CESSPOOL ❑ ORYWELL
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYS TEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DE IB RE51 IAL PROPERTY
ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACEEP KFILL
PIT'SEPT) ❑IC TANKS ❑
SCESSPOOLS
` OVALIDATION ROBERT A WOOD
LK M O CASH SUPERVISING MECHANICAL ENGINEER
LACO 1 6 2 6;3 .aL 21 1 0 A 5.00- v