HomeMy Public PortalAbout4922 PERSIMMON AVE_Sewer__ 'BRe48
.s.>;� APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARnff T OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A.LAMBIE, County Engineer ADDRESS � ,=
CASSATT D. GRIFFIN,Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.- -LL A
LEGAL
DESCRIPTION LOT NO I _ OWNER ' k,
MAIL
BLOCK TRACT ADDRESS
N0.OF BLDGS.
SIZE OF LOT` . NOW ON LOT !` CITY
USE OF
BUILDINGS DISTRICT NO. OUP MAP PROCESSED BY
BK PG
CONTRACTOR y 41
ADDRESS CONNECTION DATA
CITY TEL.NO. ` STATION DEPTH
STATE
MANHOLE REFERENCE , UPPER-
REGI
STRATION N0. r' COUNTY LOWER='
NO. DESCMPTION OV-WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER _ 40 $3,00 `
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PITS AND/OR DRAINFIELD @ $3.00 Y. CURB P.L. „ M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN-„CESSPOOL.DRYWELL,MANHOLE @ $2,00
HOUSE SEWER CONNECTING TO i,✓ P.C.NO.
PRIVATE DISPOSAL SYSTEM 0 $1.00 CO.IMP.NO. j JOB NO.
f, CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER $1.00 _
ALTER,REPAIR OR ABANDON HOUSE STATE FNCROACI3ME4T_-
SEWER OR DISPOSAL SYSTEM $1.00 PERMIT NO. _
INDUSTRIAL
WASTE APPROVAL
_ CHARGES
OVMF17S PERMIT $ 2 00 CONNECTION CHARGE"FEE
AUTHOMZATION TOTAL FEE e L) REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS I DATE ;INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. E
SIGNED THIS DAY OF-L' -19 NEW HOUSE SEWER
OWNER. OR f CONNECT ADDITIONAL
OWNERS AGENT ei� �f .. BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL El DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SSEWERS, SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY' THA I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT AM THE LEGAL/
"HER
RESIDENT PROPERTLEGALHER OF THE ABOVE
Y. BACKFILL SEPTIC TANKS 0
SIGNATURE SEEP.PITS E7 CESSPOOLS
OF PERMI
mmmmum
�F VALIDATION ROBERT A.WOOD
pLK M.Q6 cult SUPERVISING MECHANICAL.ENGINEER
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