HomeMy Public PortalAbout9257 PENTLAND ST_Sewer__ 76A 642D -CE600 -YO TI APPLIC TION FOR PRMIT
' COUNTY OF LOS ANGELES EWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
1 BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITYNEAREJ
FDERIPTION:7
PPLICANT TO FILL IN
CROSS
ST .0 /
OT NO OWNMAILTRACT AODR 65 AI �']NOWll
OON LOTS CITY TEL NO i 176 �I Z.DISTRICT NO OR MAP pq 55E0 BT/1BNPV \
ADD B CONNECTION DATA
STATION DEPTH
LICENSE NO PCL BB 1`Ty MANHOLE ATE LIC REFEREN
CE , �L^/ /1
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION `) VLENGTH FROM 'l
HOUSE SEWER CONNECTING TO /, Y CURB PL M L TO P L y
PUBLIC SEWER Q $T 00 VO PC NO
SEPTIC TANK SEEPAGE PIT OR
PITS ANO/OR RAINFIELD 300 NO
:1000 CO IMP NO
DQ /
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERM? V�3 O
PRIVATE DISPOSAL SYSTEM ® S.. 4NNN
CONNECT ADDITIO N AL BLDG OR AFFIDAVIT u♦ EUKT RECORO INSTR NO DATE U
WORK TO HOUSE SEWER ® 3300
OVERFLOW SEEPAGE PIT DRAINFIELD
E%TN CESSPOOL DRYWELt a SB Go O
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM 0 S3 GO
STATE ENCROACHMENT
MANHOLE Q $T 00 PERMIT NO d
AD,
INDUSRIAL z
WASTE APP
OWNER'S
APPROVAL
O SSNER'S PERMPT f 3 00 CHARGES
AUTHORIZATION TOTAL FEE OD CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER D TE INS; TOR SS NATURE
SIGNED THIS DAY OF 19_ L,
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(5)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL
I HEREBY CERTIFY AT I AM PROPERLY HE015TERE0 AND/OR ALTER REPAIR SEWER OR
LICENSED AS REO E BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR AM THE LEGAL OWNER OF AND INTENO TO
RESIDE IN THE E O SCR R 9 E TIAL PROPERTY ABANDON
NEC. PLUG AND
ABANDON HOUS[SEWER
SIGNATURE'
OF PERMTTT E BACKFILL SEPTIC TANKS ❑
SEEP PITIS) ❑ CESSRC0 ❑
VALIDATION C6 fo CAB"
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