HomeMy Public PortalAbout5644 PAL MAL AVE_Sewer__ iao&
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ceoe APPLICATION FOR PERMIT
�• COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL:
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A LAMM C° tT 1 gt,
M
CASSATT D GRIFFIN. Sup t of Buwldiv4 LOCALITY
NEAREST '
FOR APPLICANT TO FILL IN CROSS n
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK TRACT NAIL
ADDRE34
XO OF BLDGS
USESIZE OF LOT NOW ON LOT CITY 0 -
BUI OF
BUILDINGS DISTRICT NO 6 UP YAP PQ PROCESSED BY
CONTRACTOR LB/
ADDRESS — - CONNECTION DATA
CITY // TEL NO ZlQj' STATION D DEPTH
ATE
REGISTRATION NO�O L$ 1 COUNTY MANHOLE REFERENCE UPPER
No DESCRIP ION OF W RK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER 33 00 TYPE OF'CONNECTION LENGTH FROM
PITS IAND/OR SEEPAGEPITOR ® $3 00 T CURB P L Y L 0 P L
OVERFLOW SEEPAGE PITS DRAINFIELD -
EKTH CESSPOOL DRTW ELL MANHOLE 3 00
HOUSE SEWER CONNECTING TO P C 0 ��
PRIVATE DISPOSAL SYSTEM 3f 00 CO INP N
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO - ROAD PERMIT NO
WORK TO HOUSE SEWER 100
9 PO R A ON HOUSE 1 00E
STATE ENCRO
RMIT NO
INDUSTRIAL I If
ASTE APPROVA
CHARGES
OWNERS PEBM17 2CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMEAPPROVALS DATE INSPECTOR 9 SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DW
TO THE PUBLIC SEWER
SIGNED THIS_�gY OF ) NEW HOU9ESIT
OWNER OR CONNECT ADDITIONAL L
OWNERS AGENT l_C.C/�� BUILDING OR WORK
SEPTIC TANK SEEP PIT IS)
ADDRESS ND/OR ORA,NFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ TX14 APPLI
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO CESSPOOL DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGU LTER REPAIR SEWER OR -
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AN PROPERLY REGISTERED 019CO N,ECT PLUG AND -
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 THE LEGAL OWNER OF E DESCRIBED RESIDENTIAL BACKFILL SE IC TANKS ❑SIGNATUREEEP PITS Sol
OF PER ITTE
®. T
ION ROBERTA WOOD
tNw ■ 0. WIS SUPIERVICING MECHANICAL ENGINEER
6748 OCT391 0 A 300 M