HomeMy Public PortalAbout4941 PERSIMMON AVE_Sewer__ Iv
CES08 -64
76A642D3APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION [BUILDING
"RE All
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Supt of Building 2
NEARES
FOR APPLICANT TO FILL IN CROSS ST,
LECAL-_
DESCP PTI.2N LOT NO;,"
MAIL
BLOCK TRACT �AAODRE'S
EI
NO. OF LDGS,
.IT
SIZE OF LOT NOW ON LOT CITY TEL. NO,
USE OF
BUiL INC. A PROCESSED
PG
CONTRACTOR
ADDRESS
CONNECTION DATA
STATION DEPTH
f MANHOLE REFERENCE STATE
REGISTRATION NO.
NO. I DESCRIPTION OF Wd-RIK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L,TO P.L,
PUBLIC SEWER $5.00 4" P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR JOB NO. n-
PIT$AND/OR DRAINFIELID CO.IMP. NO. 0
i HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3,00
1 O,�—VIT WAIVX% EASEMCNT RECORD.-NSTR.NOI DATE
CONNECT ADDITIONAL BLDG.4ft
0
TO HOUSE SEWER
OVERFLOW
EXTN.,CESSPOOL,DRYW5LL,MANHOLE 0 -OO
$5 U
HWY.OR ST.WIDENING
US
Al TER,REPAIR OR ABANDON HOE 0-
SEWER_OR DISPOSAL $3�00 U)
STATE ENCROACHMENT z
PERMIT NO.
INC�STWAL 11
WASTE APPROVAL •
CHARES
OWNER'S PERMIT
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
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 V5P
.CTOR'S SIGNATURE
SIGNED THIS_—DAY OF___Ig ......
OWNER OR NEW HOUSE SEWER
OWNERS AGENT--
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS_
IHEREBY ACKNOW LEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PITIS)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY
ORDINANC ES
AND
STATE 0EGULATING
PLUMBING AND SEWERS CESSPOOL C3 DRYWELL El
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,RE I ,SEWER OR
LICENS E 0AS PEOU IRED BY LOS ANGLES COUNTY AND STATE OF SEWAGED ISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL-OWNER OF, AND INTEND TO
RESIDE: IN, THE ABOY�e_DhSCRISED �PC
_ SIDENT4 PROPERTY. CIS ECT PLUG AND
ABANDON HO US ESEWER
SIGNATURE
KS
0 F PERMITTED BACKFILL SEPTIC TAN ❑
SEEP,PIT(S) [] CESSPOOLS
VALIDATION ROBERT A. WOOD
M.O. CASH SUPERVISING MECHANICAL ENGINEER
CK_ 1 APR 8 1 0 D