HomeMy Public PortalAbout5647 PAL MAL AVE_Sewer__ TaweM¢}�r' APPLICATION FOR PERMIT 1
eee%DMSION OF BUMDING AND SAFETY I SEWER—SEWAGE DISPOSAL
1 Department of County EngLne
County of Los Angeles BUILDING /
' JOHN A LAMBIE COUNTY ENGINEER ADDRESS !O
® CASSATT E) GRIFFIN SUP TOK BUILoINQ LOCALITY
FOR APPLI TO HROSSS sT
LEGAL OWNER
DESCRIPTION LOT NO rVp
BLOCK TRACT MAILADDRESS
NO OF BLDGS
SIZE OF LOTZ40 NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP NAP
BK P6
CONTRACTOR �a
ADDRESS CONNECTION DATA
CITY TEL NO STATION / P DEPTH
MANHOLE REFERENCE (UPPER!
[j STATE
LOW R
REGISTRATION NO ❑ COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTIOrj�' LENGTH FROM
PUBLIC SEWER @ $3 50 S_v Y CURB /P L Y L TOP L
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q S 3 00
OVERFLOW SEEPAGE PIT DRAINFIELO P C NO
EXTN CESSPOOL DRYWELL MANHOLE ® $2 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSALSYSTEM ® 51 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® 51 Do PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM 05 100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT S 1 00
AUTHORIZATION TOTAL FEE REIMS URSE HENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ! J
TO THE PUBLIC 5W NEW HOUSE SEWER _
SIGNED THIS AY F 1 CONNECT ADDITIONAL _
OWNER OR BUILDING OR WORK '
OWNERS AGENT SEPTIC TANK SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ ORYWELL❑
AND STATE THAT THE ABOVE IBC'
AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWEROR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AY PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE EGAL IER OF THE ABOVE
DESCRIBED RESIDE L P ERT BACKFILL SEPTIC TANKS❑ G
SIGNATURE SEEP PIT(S) C1 CESSPOOLS O
OF PERMITTEE
JOHN A LAMBIE 'COUNTY ENGINEER VALIDATIO ROBERT A WOOD CHIEF PLBG INSPECTOR
CK Y 0 CAfN
L&0 4 0 99R "APR 3'0 4 A yn 4.50 'A