HomeMy Public PortalAbout5645 PERSIMMON AVE_Sewer__ 6A,542D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES , SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE, County Engineer ,IEA
-- , 1 -- ------------
WILLIAM A. JENSEN, Supt of Building
LOCALITY
_�G
,-P A R,
,1EARFST
C 0_S
CROSS Sr
FOR APPLICANT TO FILL IN
LE AL.
LOT NO.
BLO!K TRACT MAIL
ADDRESS
NO. OF BLDG'S.
SIZE Orl- T NOW ON LOT CITY f'FL. NO.
USE FLAGS OF DISTRICT NO, MAP
rROCE�SSEII BY
BU I LD
13 K PG
CONTRACTOR
A
ADDRESS
CONNECTION DATA
STATION DEPTH
CITY TEL NO.,'. ✓
STATE
REGISTRATION NO COUNTY MANHOLE REFERENCE .'V 'UPPER
II -.,:.0
NO 1 DESCR!RTIO'N OF WORK FEE TYPE OF C:5�-�, EZ.TION LENGTH FROM
HOUSE SEWER:TONNE CTINGTO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER $5.00
P
5EPTIC TANX,AND/OR
PIT. OR I CO.tMr.NO. jo's NO.
FIIS AND/ODRAINFIELD @ $U 0.00
V3O115E SEWER TING TO
DISPOSAL SYSTEM $3.00 TRUNK PERMIT NO. ROAD PERMIT NO. L/, J 0
AFT-RE--
�IDXVFT W—AIVER EASEMENT CORD- INSTR-110* Aye-
WORK TO HOUSE SEWER $3.00
• OVER FI.QWS�CEPAGE PIT,ORAINFELD-
I EXTN..�ESSPOOL,DRYS/ELL,MAN HOLE@ $500
z
A-'&`D-0-N--H0-U SE— HW Y.OR ST,WIDENING
'SEWE"R DISPOSAL SYSTEM @ $3.00
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT s2� 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON RLiMBURS-EMEN-T FEE
T A f--O�,INECT TE BOVE DESCRIBED EXIST ING DWELLING
`�T 0F� HA
T n THE
p
E ULILAC SEWDATE
LR� APPROVALS NSPEC FOR S DATE ..
SIGNED THIS— Ay.r OF'-----
CWNER OR NEW HOU SF SEWER
OWNERS AG -- ----
CONNECT ADDITIONAL
BUILDING OR WORK
TA
AD-
SEPTIC TANK-SEE",PiT(S)
I iw,EEOGF THAT I HAVE" AD THIS APPLICATION '
AND
HS TL I 4AT ','.HE ABOVE IS CC;FtRtCT AND AGREE TO COMPLY
ANOCIR D4AINFIELD
WITH ALL. COUNTYORDINANCES' AND STATE LAWS REGULATING
PLUMBING AND nEW E RS. CESSPOOL ❑ DRYWELL
HERESY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,RE.PAjR.SEWER OR
LICENSED
AS REOUTRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CAL I FORNiA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO
DISCONNECT PLUG AND
RESIDE
IN, THE ABOVE; DES(,Rl DEC) RRS!DENrIAL PROPERTY.
ABANDON HOUSE SEWER
SIGNATURE
OF I-ERMFTTFE BACKriLL SEPTIC TANKS
sEEP Prc(S) 0 CE5spoc),-.s(
7VALIDATION ROBERT A. WOOD
K. M.0, CASH SUPERVISING MECHANICAL. ENGINEER
6A64:E64 6A6420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL `UDEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FRE
JOHN A. LAi�lBIE, County Engineer 7VWILLIAMd A. IENSEN, Supt of Building
FOR APPLICANT TO FILL IN
L C4L ...LOT NO J OWNER ��
DESCRIPTION ,-� _-_ _-. _ -.. _—d`p
BLOCK TRACT /> � � '� -__-_..__-__--- ADDR F.SS' -. 'Y✓�I�_! d�R.! � J P� /'a_ef�'#.•_�e.�_____..._
s' NO. OF BL OGS. <. +. •/}'.
SIZE U : T ..',f '.' NOW ON LOT CITY a c, `. TEL. NO. '
_O_.
USE OF
DISTRICT NO.
BUILDINGS BK PPGGROUP MAP PR(1O ESSED SY
_ 1
CONTRACTOR &+ v' �f l�_� ,,7�-.L✓xj L .>-{,.
ADDRESS — !! — CONNECTION DATA
T STATION �' DEPTH' ✓ /� ✓
CITY yeL TEL NC. t
REGISTRATION NO.,. � COU E • " UPPER
MANHOLE REFERENCE ✓ �jj�� -
LLL... NTY _.._✓�� 4-_- �� � 4�T.."OWER;j.
NO.
]DESCRIPTION OF WORK FEE �TYPE OF CONI TtCN LENGLT'K FROM r
HOUSE.S-WER CONNECTING TO ��- � Y. S'CUR3 _---P.L. WL TO P.L. 'j J
PUBLIC SEWER -=_F+ �^ f f- s�
SEPTIC TANK.SEEPAC L ell. OR '- "- ".C.NO.
CO. IMP, NO. >
OB NO, `
PITPITS;AMD�OR DRAINFIELD @ $10.00 �-
HQUSE SEWER COhNE=T!NG TO �, TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $9.00
CON NC.T ADD ZONAL BLDG.OR fi AFFIDAVIT wn;v€s ens Cm£i�e�R£C067D.t.N.STR NO. DATE.
WORK TO HOUSE.SEWER @ %1.04
-- - - - --
OVERFLOW SCE PA-6i-PTT-p1T URAlNFIELD
EXT^i CESSpOOL.,DRYWELL,MANHOLF,@ $5.00
.__ _.—. _. ..__-_ HWY.OR ST.WIDENINGS
AI 7ER.REPAIR OR ABANDQN HOUSE
SEWER OR DISPOSAL SYSTEM �_—.. a-
STATEENCROACKMENT
--- -i PERMIT NO.
INDUSTRIAL
(� ✓..l //
WASTE APPROVAL _. -
C—HAFdG ES'
OWNER'S PERMIT 5 00 _-- ---- -- _---
-____ -t" / _.. CONNECTION.CHARGE.FEC
AUTHORIZATION TOTAL PEE
'I HAVE AT THIS DATE. A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMEN?`FtEEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING /�;_p -
TO 7HE PUaL IC SEWER. APPRO PALS 1 DATE I INSPECTOh.,SIGNA.?URE
SIGNED THIS—DAY OF 19_ ------ __—._. ---------� ----....__._
-— ---
OWNER OR NEW HOUSE SEWER
OWNERS AGENT-_-_
CONNECT ADDITIONAL
--- BLIILDING OR WORK -
ADDRESS--- _ _ --_.
—� D AND/QR DSFPTic NAINF£LD P. IT(u) F
TO COMPI-Y
W,T SALL THAT TF{E AHOVE E CORD STATE LAWS REGULATING CESSPOOL ❑ QRYW ELI t...--�- I ---------- -
I HFRk BY Ar .KNOW LTLPE THAT 1 -fAVF READ THISAPPLIr'AT'ION I
1YITR ALL COUNTY ORDINANCES AND
PLUMBING ANG SEWERS,
1 HERESY CERTIFY THAI' I Ail, PROPERLY RFGIS:ERED AND/OR ALTER REPAIR.SEWER OR 1
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSALSYSTEM.
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO -----'--"-----`T----- - - r-- '- --- T-
RES 1DE IN. 'HEABOVE DESCRIBED RESIDENTIAL PROPER-Y, D CONNECT PLUS' AND I
SIGNATURE a+'r"". .. TI —...._
/ �/� �yy' ,J/ ,y� ABANDON HOUSE SEWER
0F' PERMITTEE I ®sr'�'-_y+m"f ✓' a"r` '_, '� ✓ 'tel` BACKFILL SEPTI TAkKS
- - SEEP,PIT i5l CESSPOOLS �I �
fVALIDATION, ROBERT A. WOOD
SUPERVi SING MECHANICAL ENGINEER
CK, F.S.O. �`CASH
LALO 6 S 08 53 OCT 2 6 1U
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