HomeMy Public PortalAbout9024 PENTLAND ST_Sewer__ 76008505
0A 042 D APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING �y q
JOHN A 1 A\11311 County I ngine,r ADDness .c Ciy//` A,,
COLE\IA\ R 1F\AI\5 Sup t of Bu Jd,.g
LOCALITY E�10�,� L'/I
NEAREST
FOR APPLICANT TO FILL IN GRosa 5T �C A1Fl�D
L AL EL F
DESCRIPTION LOT NO OWNER
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BLOCK /{TRACT ADDRESS / /�A
SIZE OF LOT
V �I NOW F LOTS / CITY l C•/T TEL NO 4 %VO
USE OF
9 Q� � �
BVILDIN6i DISTRICT NO GROUP SK MAP PG P�ROCESSED BY
CONTRACTOR �T� �6NAM CI
ADDRCGS L A// 10, 1 CONNECTION DATA
&4,0jCITY lI"K Vy` TEL NOoer Ire STATION DEPTH _
LICENSE LICENSE
NO CLASS
MANHOLE REFERENCE d
Katz
OWrBR
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FR
HOUSE SEWER CONNECTING TO C'�.. Y CURB M L TOIL
PUBLIC SEWER C $ 5 00
-MgSEPT It POCB NO
PITS ANflNO
a
O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO V
PRIVATE DISPOSAL SYSTEM @ S 3 00
CONNECT ADDITIONAL SLOG OR AFFIDAVIT uv gi[Civl RECORD INSTR NO DATE
WORK TO HOUSE SEWER f $ 3 00 O
SEWER OR DISPOSAL SYSTEM '$ $ 3 00
HNY OR BY WIDENING a
E%TN CESSPOOL MANY.LE C $ 5 00 STATE ENCROACHMENT y
PERCOLATION TEST L $ 5 00 PERMIT NO Z
INDUSTRIAL
WASTE APPROVAL
OWNERS pEAMIT s i 00 CHARGES
AUTHORIZATION I TOTAL FEE CONNECTION CHAHGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED ON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER DATE MSPEC R B SIGNATURE
SIGNED THIS DAY OF 19_ A
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK SCEP PIT(S)
IMEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINPIELD
ANO STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 THE LSI
EGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
B O S
RESIDE IN THE ACRIBED REDENTIAL OPERTY ABANDON HOUSE SEWER
SIGNATURE C
OF PERMITTEE BACKFILL SEPTIC TANKS ❑ /M�/ w
SEEP PITIS) ❑ CESSPOOLS
o V ALIDa�
CK M CA9X
'°A°'°°2D
°E 12 54 APPLICATION FOR PERMIT 1
DMSION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
Ccnnty Of Los Angeles ADDRESS G Q
_ WM J FOX COUNTY ENGINEER
CASSATT D GRIFFIN BUP T Or BUILDIMa LOCALITY
FOR APPLICANT TO FILL IN NEAREST
LROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP YAP
BK PG
CONTRACTOR {
ADDRESS /,d J CONNECTION DATA
CIT - TEL NO e&,,(O #1 / STATION DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO of/ ❑ COUNTY UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
NO DESCRIPTION OF WORK FEE Y tuna P L M L TOP L
HOUSE SEWER CONNECTING TO
PUBLIC SEWER ® $ 3 SO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 GD _
CONNECT ADDITIONAL BLDG OR CO IMP NO JOB NO
_ WORK TO HOUSE SEWER 1 00 _
ALTER OR REPAIR EXISTING
_ SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
,DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
rTIC TANK SEEPAGE PIT OR
ITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL DRYWELL •+ WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 ^ CHARGES
CONNECTION CHARGE FEE
OWNER'S PEIiMiT S 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE TRACTOR'TO DATE CONNECT THECTED ABOVEWITH THE DESCRIBEDH EXESTINGIN AMED DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS Y OF 19 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD ee
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
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS AN ES COUNTY AND STATE OF DISCONNECT
HOUSE SEWER
CALIFORNIA OR TH T A HE L OWN OF THE ABOVE
DESCRIBED RESI DEN P TY BACKFILL SEP IC TANKS❑
SEEP PIT(S) CESSPOOLS
SIGNATURE _
OF PERMITTEE
WILLIAM J FOX COUNTY ENGINEER VALIDATION
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