HomeMy Public PortalAbout5639 PERSIMMON AVE_Sewer__ a e.sE-6Des�t•ss
3APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER--SEWAGE D i S POSA L
Department of County Engineer
County of Los .Angeles BUILDING Q c` {
A-DDRESS ;,.,. ..� ,----F-- •- -
.JOHN A. LAMBIE, COUNTY ENGINEER -----
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11) CASSATTD. GRIFFIN, SUPTOFBUILWNG _LOCALITY F .
FOR APPLICANT TO FILL IN CROSS S
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LEGAL ttj I - y"s
OWNER
DESCRIPTION _LOT NO, .__---------- t' y x 4. •f �,�.
BLOCK - TRACT "� ---� ---- MD
ADDRESS s �fL
NO.OF B DGS. CITY TEL. N0.
SIZE OF SLOT NOW ON LOT =l , y e
USE OF -
BUILDINGS._ �C '; - DISTRICT NO. GROUP MAP
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CONTRACTOR _j—
CONNECTION
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ADDRESS '` > a All
CONNECTION DATA_ --
STATION a6' c'-• f DEPTHic
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CITY .r�"' ,j"'L-..—�.--'l TEL N0. ! g s 5 - - Upp
' ._ h1ANHOLE EF`R NCE -. � ;� _:�,-
' STATE
REGISTRATION NO, 'rT �y � _� 7' ❑ COUNTY -
-NO-�- DESCRIPTION OF WORK FEE -- - --- - — - ----- -
HOUSE SEWER CONNECTING T6
�dam. TYPE OF g0l"MECTION _ LENGTH FROM
_ I PUBLIC SEWER - _.-- ----- �A, $3_:50 � ._•I,':'� M.L. TO P.L. -#------
SEPTIC TANK,SEEPAGE PIT OR -#--
_� PITS.AND/OR DRAINFIELD _ - (c% $_3.00
OVcRFLOW SEEPAGE PIT,-D-RAIN FIEL
_RAINFIELD P, C. N0,
I EXIN„CESSPOOL,DRYwELL,MAN 14OLE (� — CO. IMP_NO, JOB N0.
HOUSE SEWERCONNECTINGTO I -
_ PRIVATE DISPOSAL SYSTEM ([i. $1.00 � — TRUNK PERMIT.NO. - ROAD PERMIT NO.:r
CONNECTADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEXIER ai, $1,00 PERMIT NO,
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
I SEWER OR DISPOSAL SYSTEM �� $1.00 WASTE APPROVAL
—I— `--- --- - ------' +------ - -
CHARGES
---_—_-__ -- -
-E_-- __ -- CONNECTION CHARGE FEE
OWNER'S PERMIT _$ , 00 ----------- - - ---'------- ._
- REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
�1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS ! DATE INSPZCTOR'SSIGN.ATURE
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TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEVER. NEW HOUSE SEWER
SIGNED THIS --DAY OF.-_—_ coNNECT ADDITIONAL --
OWNER OR BUILDING OR WORK 11
OWNERS AGENT-
—_..�-.�..�__—._:___. ._�_.-.._.— SEPTIC TANK,SEEP,PIT l51
ADDRESS_..-_: AND/OR DRAINF'ELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
CE$SPOOL0 DRYWELLr,
CJ
AND SATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNT, ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
S HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON CT PLUG AND I ,
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON
SE - -- --
DESCRIBED RES C TIAL PROPERTY, BACKFILL SEPTIC TANKS[I
SIGNATURE SEEP.-- - - CESSPOOLS - - ---�
OF PERMIT r
10HN AMB N?�01 VALIDATION ROBERT A.WOOD,CHIEF PLBG. INSPECTOR