HomeMy Public PortalAbout4914 PERSIMMON AVE_Sewer__ �f
`6A642D67 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL:
DEPARTMENT OF COUNTY ENGINEERR
BUILDING AND SAFETY DIVISION BUILDINGS r�
LOAN A, LAMBIE, County Engineer ADDRESS
WILLIAM! A. JENSEN, SuP't of Building LOCALITY
NEAREST t
FOR APPLICANT TO I°"II.I. IN CROSS 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 MAP PROC£SSBD BY
y BK PG
CONTRACTOR r Y f 2/ a
ADDRESS ` �" - CONNECTION DATA
CITY �S�p-rr _;TEL.NO.< i': � a_ STATION _i- ' DEPTH
i
t �;_W." STATE MANHOLE.REFERENCE "
REGISTRATION NO, ,y�, ❑ COUNTY - LOWER
NO. DESCRIPTION OF'W_ RK FEE
HOUSE
OUS GSEWE SEWER
TOPUBL $�8^ 0 t
TYPE OF1z . CONN
TYPE LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.1..- M.L.TO P.L.
PITS AND/OR DRAI
NFIELD @ $9.00
OVERFLOW SEEPAGE PIT,DRAINFIELD y
ERTN...CESSPOOL.DRYWELL.
HOUSE SEWER CONNECTING TO "- P.C.NO. 0
PRIVATE DISPOSAL SYSTEM 'Ce $1.00 Co.IMP,NO.. � _.`� JOB NO. L)
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO, -�-
WORK TO HOUSE SEWER 51.00 w
ALTER;REPAIR OR ABANDON HOUSE NATE ENC$OAGHMENT
SEWER OR DISPOSAL SYSTEM $1.00 _PERMIT N0. IJ
INDUSTRIAL W
WASTE APPROVAL D,.
6n
CHARGES Z
ovam'R PERMIT 2 00 CONNECTION CHARGE FEE
AUTHORMATTON TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF--19— NEW HOUSE SEWER
OWNER OR pI ,,. i '� ... CONNECT ADDITIONAL
OWNERS AGENT - �' -`I"T"'2:I,+:..ia:._.• BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)
AND/0R DRAINFIELD
--I HEREBY ACKNOWLEDGE THAT IHAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE iS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ ORYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBINGANDSEWERS. SEWAGE DISPOSAL SYSTEbl
1 HEREBY CERTIFY THAT I AM 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 LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDEpMAL PROPERTY A BACKFILL SEPTIC TANKS ❑
SEEP,P1TdS ® CESSPOOLS
SIGNATURE �. s r }..,.
OF PERMITTE �
VALIDATION ROBERT A.WOOD
F, GK,' 2.0. cum SUPERVISING MECHANICAL ENGINEER
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