HomeMy Public PortalAbout5551 PERSIMMON AVE_Sewer__ C`b,;`kt\, �:'a APPLICATION FOR PERMIT
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SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
DISTRICT NO GROUP MAP SSED BY
FOR APPLICANT TO FILL IN _ t PG i
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ry
BUILDING _ V1.
ADDRE 55 �. +
LOCALITY ��-
CONNECTION DATA
'_____
NEAREST - • STATION DEPTH
CROSS ST.
--- UPPER
MANHOLE REFERENCE LOWER
OWNER .a `._1_ 1 c
TYPE OF CONNECTION - LENGTH FROM
MAIL ,,. y M.L.TO P.L.
ADDRESS MOW./`zd�_ CURB
P.C.NO.
t CO.IMP.NO. JOB NO.
CITY 4 � �.._ TEL.NO.
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT HWY,OR ST.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
Lr INDUSTRIAL
CONTRACTOR WASTE APPROVAL g
ADDRESS 1y CHAR E:
y CONNECTION CHARGE FEE
CITY
STATE LIC. REIMBURSEMENT FEE
LICENSE NO. �- CLASS ._ okO
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECT'OR'S SIGNATURE V
HOUSE SEWER CONNECTING TO 99
PUBLIC SEWER C
NEW HOUSE SEWER
SEPTIC TANK,SEEPAGE PIT OR
ITS AND/OR DRAINFIELD CONNECT ADDITIONAL -
HOUSE SEWER CONNECTING TO BUILDING OR WORK -- '
PRIVATE DISPOSAL.SYSTEM
SEPTIC TANK,SEEP,PIT(S) V�
CONNECT ADDITIONAL WdN4PW&R AND/OR GRAINFIELD z
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL ❑ DRYWELL❑
EXTN..CESSPOOL,DRYWELL,MANHOLE
ALTER.REPAIR OR ABANDON HOUSE ALTER,REPAIR.SEWER OR
SEWER OR DSPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑ _
Permit $ SEEP,PIT(S)E: CESSPOOLS
OWNER'S ''
AUTHORIZATION TOTAL FEE VALIDATION
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING j� �---,
TO THE PUBLIC SEWEf#. i. yli�Q f'qv
SIGNEDTHIS '� DAY OF _ `�- .' 19b N
OWNER OR
OWNERS AGENT
ADDRESS
A
I HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS RE'OU IR
ED BY LO$ ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF,AND INTENDTO RE-
SIDE IN,THE ABOVE DESCRIBED RESIDENTIAL PROPERTY.
SIGNATURE
OF PERMITTEE