HomeMy Public PortalAbout9406 PENTLAND ST_Sewer__ CE80810-e3- "- ""'f
Te A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION emLD1Nc O
JOHN A LAMSLE CODGIY Evqq.BbT ADDge6s
WILLIAM A IENSEN SUP 1 QI Eulld[Bq
LOCALITY
NEARC5T
FOR APPLICANT TO FILL IN CROSS ST
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DESCRIPTION LOT NO OWNER
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BLOCK TRACT / L,J— / GZ� ADDRESS
NO OF SLOGS
612E OF LOT NOW ON LOT / CITY TEL NO
O
USE F D18TRICTNO GROUP MAP CE6BED BT
USE NOS
CONTRACTOR S 5 v !l W
ADDRESS CONNECTION DATA
CITY /) TEL NO d STATION DEPTH
REGISTRATION NO Q[ 60UNTY MANHOLE REFER QNCf / UPPER
NO GESCRI PTION OF WORK FEE TYPE OF CONNECTION LC OTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L
PUBLIC SEWER m $300 }
SEPTIC TANK SEEPAGE PIT OR PC NO d
PITS AND/OR GRAINFIELD ® $1000 CO IMP NO JOB NO O
NO BE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
P RIVATE DISPOSAL SYSTEM Q S3 OO K
CONN ECT ADDITIONAL BLDO OR /a AFFIDAVIT v[I [A[[s[xT RECORD INBTR NO DATE OF
WORK TO HOUSE SEWER o 5300 C/ V
OVERFLOW SEEPAGE PIT GRAINFIELD W
EXTN CESSPOOL DRYWELL MANHOLE® 33 00 / NIG
R 1
ALTER HWTO8 D[REPAIR OR ABANDON HODS[ yJ
SEWER OR D
ISPOSAL SYSTEM ® 1300 STATE ENCROACHMENT Z_
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGEE
OWNERS PERMIT S AO0
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR E SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGSHT
CONNECT ADDITIONAL
AGGRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(5)
ANO/OR GRAINFIELD
AND STATE THAT THE ABOVE ICORRECT AND AGREE
WITH ALL COUNTY ORDINA NCES ANO STATE LAWSWSRE COMPLY
REGULATING ❑
PLUMBING AND SEWERS CESSPOOL ❑ DRYW ELL
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED IAND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY 8 ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 A H LEG OWNER OF D INTEND TO DISCO NNECT PLUG AND
RESIDE IN THE ASO V S8 SI DCNTI P PERTY ABANDON HOUSE SEWER
L/
SIGNATURE BACKFILL SEPTIC TANKS
OF PERM ITTQ[ SCEP PITIS) ❑ CESSPOOLS ❑
VALIDATION ROBERT A WOOD
� c M o CASH SUPERVISING MECHANICAL ENGINEER
IAL05 3l 4 1 r' SEP 7 1 d D 5,0 0- r
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