HomeMy Public PortalAbout5415 PERSIMMON AVE_Sewer__ TIll-7
°8842. APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRE xc :-
ADDRESS
TORN A. LAMBIL County Engineer - e
CASSATT D. GRIFFIN, Supt of building LOCALITYr�
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL j r ✓ i 4.
DESCRIPTION LOT NO. _OWNER
BLOCK TRACT �y p MAIL s #
:> j t�,TN _ADDRESS
N0..OF
BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. N0. '
USE OF
BUILDINGS DIISTRIICTq
STATIONNrO. GRC�OU..PI1lL j MAP �PROCESSED BY
CONTRACTOR " l
,
. a if h7 _ 1 Ali B P
ADDRESS� CONNECTION DATA
CITY TEL.N0. ,�1 DEPTH
❑ STATE MANHOLE REF ENCE UPPER
REGISTRA N N0. ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO -
PUBLPC SEWER (v $3.00 TYPE OF CONN CTION LENGTH IfROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3,00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO <;' P.C.NO,;
PRIVATE DISPOSAL SYSTEM @ 41,00 CO.IMP. NO. JOB tr'
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ,-2208.PERMIT N0.
WORK TO HOUSE SEWER @ $1.00
6..-
,4tREPAIR OX-AFA'N-D"HOUSE STATE ENCROACHMEN -
S ER C►R-D4S0084LS4 "`M @ $1,00 PERMIT NO. -
INDUSTRIAL
WASTE APPR X
C GES
OWNER'S PERMIT 5 2 00 CONNECTION CHARGE FEE �v
AUTHORISATION FTOTAL FEE r REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATr INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.. �,,
SIGNED THIS `° AY OF__4 ' ,'- 19 I NEW HOUSE SEWER
P 1 f
OWNER !*t CONNECT ADDITIONAL
OWNERS A AGENT Iri �� � ;�+"v+- -�' +�- �'� _BUILDING OR WORK
ADDRESS - - `+�-�� �� + ;& .t`�- .f. '- SEPTIC TANK,SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS A PLICATION-
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ -
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE GAL OWNER OF THE ABOVE
DESCRIBED RESID NTIAL PROPERTY. BACKFILL SEPTIC TANKS ❑ -
SIGNATURE >'.�'' SEEP.PITS) ❑ CESSPOOLS ❑
OF PERMITTEE ` r ��C
�f VALIDATION ROBERT A. WOOD
'"
C$. U.0. CASA
SUPERVISING MECHANICAL ENGINEER
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