HomeMy Public PortalAbout4937 PERSIMMON AVE_Sewer__ ESD
Sa -ss�11-ss
APPLICATION FOR PERMIT Z
3 a�
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING -
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS _
ED CASSATT D. GRIFFIN, SUF"T OF SU1LDING LOCALITY
NEAREST
----- -FILL APPLICANT TO FILL IN CROSS ST
--------
LEGAL - ---- _...-- --. --- -- -- -- __
DERIPTION LOT NO. OWNER
SC
- ---- - --- MAIL --------
BLOCK ,. TRACT - ADDRESS
- NO. OF BLDGS, CITY 7�L. N0.
SIZE OF LOT NOW ON LOT
USE OF DISTRICT NO. GROUP MAP
BUILDINGS. _ < BK PG
CONTRACTOR
CONNECTION DATA
ADDRESS ---- ----- - ----
- 'e
STATION ��p-,�,° D£PTF3
.
CITY - TEL. N0. _._ _�._5...r r� ---i'c-----�
- -- ----- - -- -- ?MANHOLE REFERENCE r U
STATE
REGISTRATION NO, ❑ COUNTY
N0.-_.I DESCRIPTION OF WORK FEE ----- ----- --- --- ---
HOUSE SEWER CONNECTING TO .-- -- TYPE OF CONNECTIO -- LENGTH FROM
PUBLIC SEWER _ CURB i�`C--�- - M.L.TO P L. ..._
SEPTIC TANK.,SEEPAGE PIT OR �
PITS AND/OR DRAINFIELD 'Cq $5.09
----- --- --- - Y--= .�
OVERFLOW SEEPAGE Pit DRAINFIELD P, C. NO.
EYTN.,CESSPOOL,DR(WELL,MAN HOLE G+i $2.00 -- I -- CO. IMP NO. -. ` _JOB NO.
--'�
HOUSE SEWER CONNECTING TO --- ----�-- - -- -- —_ -
PRIVATE DISPOSAL SYSTEM Ca $1.00 i 1 TRUNK PERMIT NO. ROAD PERMITNO,
I CONNECT ADDITIONAL BLDG.OR -
;�I STATE ENCROACHMENT
j WORK TO HOUSE SEWER - 0, $1,00 `
PERMIT NO,
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
iScJ'J£k OR DISPOSAL SYSTEM (+. $i.GO WASTE.APPROVAL -
CHARGES
1INNICT101 CHARGE PEE
OWNERS PERMIT 00 :---
- - -- REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE � APPROVALS
;;ATE IINSPECTOR'S 5i;;NATURE
1 HAVE AT THIS DATE A� CONTRACT WITH THE HEREIN NAMED CON- _ ^—
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DW EI.LING j
TO THE PUBLIC SI.d:ER, NEW HOUSE SEWER �
CONNECT ADDITIONAL -
SIGNED'fH15___ DAY NIdE --
OWNER OR. - L'UILD(NG OR WORK
OWNERS AGENT... SEPTIC TANK,SEEP,PIT LS) --� -- -- ----
ADDRESS AND/OR DRAINFIELD
Y HEREBY
ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL Ll DRYWELL[}__I
-- - ------r--..--
1TH ALL COUNTY, ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
-.PLUMBI.NG AND SEWERS. SEWAGE DISPOSAL SYSTEM
I
--P -_._ -j--------r----- --------
T PROPERLY REGISTERED ATE OR DISCONNECT PLUG AND i
LICENSED THAT I BY C'i LEGALLES
COUNTY F STATE OF ,13ANDON HOUSE SEWER �
- CALIFORNIAEORAc CR REQUIRED u „r, OWNER OF THE AGOVE ---- - ----- - --- ---._- -- -------
1 HERESY CER'TIF THAT Y AM PROPER
DESCPIBE'D RESIDENTIAL PROP117,R,Y. �% EACKt ILL SEPTIC TANKS L __ +
SIGNATURESEEP PIT IS? i_; CESSPOOLS 3�'
OF PERRITTEE -
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION, ROBERT A. WOOD, CHIEF PLEIG. INSPECTOR
CK. N. Q. �AS,B
wo
yr