HomeMy Public PortalAbout5644 PERSIMMON AVE_Sewer__ 7SA6410
fi.669 12154& -66APPLICATION FOR PERMIT ],
- B
DIVISION OF B` MDING AND SAMY SEWER---SEWAGE DISPOSAL
Department of County Engineer
County of LOS Angeles BUILDI
J. FOX, COUNTY ENGINEERADDRES7---
WM.
CASSATT IA.GRIFFIN,$UP•T of BUILDING LOCALITY
FOR APPLICANT' TO FI L IN NEAREST
CROSS ST.
LEGAL. -
DESCRIPTION LOTNO. —� OWNER
BLOCK TRACT ;NAIL e�. -
-- - - --- ADDRESS
NO. OF BLDGS. - ----
_SITE OF LOT NOW ON LOT CITY TEL, NO.
USE OF --�
BUILDINGS -- _ DISTRICT NO. GROUPI MAP
CONTRACTOR ,
ADDRESS — CONNECTION DATA �A�r
k:te� 7*_L. NO...._�......_ _..�....---. STATION v'3 � � 7 DEPTH fir• �'
Ir
Q STATES MANHOLE REFE:2ENCE
REG;STRATiGN NO, C7 COUNTY _ '7
TYPE OF CONNECTION LENGTH FROM --�
No. DESCRIPTION OF WORK FEE CURB M.L.TO P.L. .-A %3 —
MOUSE SEWER CONNECTING TO I
UELIC SEWER _ x? $ 3.50
{ HOUSE SEWER CONNECTING TO -
PRIVATE DISPOSAL SYSTEM 1.00_
CONNECT ADDITIONAL BLDG. OR I! CO. IMP. NO. JOB. NO.
WORK TO HOUSE_SEWER 1.00
--
�� ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
OISC.ONN Cf AND ABANDON SEWER I STATE ENCROACHMENT
_ At 0 OR DISPOSAL SYSTEM_ 1.00 11I PERMIT NO.
SCP 7(, 16�lY S L°dGE PIT 0R I
PICS ANO/OR D4AIN:FIELD 2.00 1 INDUSTRIAL
CESSPOOL LRY4VELL-- ^� _ WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 I� CHARGES
CONNECTION CHARGE FEE
OWNER'S�1Tp� PERMIT --- �� 1 i 00
AUTHORIZATION TOTAL FEE f REIMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- APPROVALS DA7s'; INSPECTOR$SIGNATURE
TRACTOR TO CONNECTTHE ABOVE DESCRIBED EXISTING DWELLING _
TO THE PUBLIC SE'WiP. - - —_ -__--
NEW HOUSE SEWER
SIGNED THIS
OWNER 01, CONNECT ADDITIONAL
OWNERS AGENT- _______,-._— ____�.. "�.. ." _BUILDING.OR WORK— _ —
SEPTIC TANK,SEEP, PIT(S)
ADDRESS. __AND/OR DRAINF IELD
I HEREBY ACKNOWLEDGE THAT I HAVE READTHIS APPLICATION CESSPOOL 0 DRYWELL C3ND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY —
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEU
I HERESY CERTIFY THAT I AST PROPERLY REGISTERED AND/Ox "�
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE __ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
CE_SSPOOLS
SIGNATURE
OF PERMITTEE
ILLIAM J. FOX.COUNTY ENGINEER VAMIATION
By 4.50
DEPUTY - DEPUTY
ry BY
63. DEPUTY o..x,` .`�'- :✓$z- !°'..r. ..' DEPUTY