HomeMy Public PortalAbout5639 PAL MAL AVE_Sewer__ CE00830= APPLICATION FOR PERMIT
TeAeAao COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
COLEMAN W JENKINS SUPT OF BUILDING /7 .
LOCALITY (C
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST
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O[SCRIPIION LOT NO I OWNER G
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SIZE OF LOT OW ON LOT CITY �Q .O lftLJN
USE OF DISTRICT NO GROUP MAP PROCES6BO BY
BUILDINGS
O BK PG
CONTRACTOR
ADDRESS CONNECTION DATA
CITY O O STATION DEPTH
TE ' LIC UPPER
MANHOLE REFERENCE
LICEN 3E NO CLASS LOWER
NO
DESCRIPTION OF K '-FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO v Y CURB P L M L TO P L
PUBLIC SEWER d tB 00 O
SEPTIC TANK SEEPAGE PIT di i1 PC NO
PITSAND/ORDRAINFI ELD 8 11000 CO IMP NO JOp NO lJ
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO K
PRIVATE DISPOSAL SYSTEM ® 53 00 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVERuSae GIT RECORD INSTR NO DATE
WORK TO HOUSE SEWER Q 1300 V
W
OVERFLOW SEEPAGE PIT DRAINFIELD
E%TN CESSPOOL ORYW ELLL M.MA N.0 MOLE a
SB 00
ALTER MOOSE HWT OR ST WIDENING z Z
SEWER S30O STATE ENCROACHMENT
PERMIT NO
INDV STRIAE
WASTE APPROVAL
X Ge
j,ppWNER'9 PERMIT s z DD
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEB
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR 8 SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTICTANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ANO/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING CESSPOOL [3 ORYW ELL ❑
IPLU MBING AND SEW EHE
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AHO/ORp
REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OFGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TONNECT PLUG AND
RESIDE IN THE AS E DESCRIBED RESIDENTIAL PROPERTY DON HOUSE SEWER
.,.NATURE ILL SEPTIC TANKS ❑
OP PERMTTT PLL,SE ❑ CESSPOOLS
VALIDATION/ JACK R ALLEN
CK Al O CASH iSUPERVISING MECHANICAL ENGINEER
,+ 9 4 0 6% APA 17 1 0 D 590- -
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