HomeMy Public PortalAbout5651 PERSIMMON AVE_Sewer__ A 0
iF:•6663 9Y-55 APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDINGe 1 r
JOHN A. LAIVIBIE, COUNTY ENGINEER A=DDRESS �,' �• .t> � .t�1,a.�5t%..�,�t,L �.;,^-:,,T �,>,��'�,,.:i4.
CASSATT ID. GRIFFIN, SUP T OF BUILDING? LOCALITY
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FOR APPLICANT TO FILL IN NEAREST �(
LEGAL _-- ------ - - ------ ---- =�--- �, �=_ _—.— .__�
DESCRIPTION LOT N0. j OWNER � ..A 4—
BLOCK TRACT j Z�` '`` MAIL
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SIZE OF LOT /,i, hOW ON-LOT /t CITY . `, -v;o_ ._ TEL. NO. - �
USE OF ; '"
BUILDINGS DISTRICT N0. GROUP MAP
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CONTRACTOR -( J ,..� :✓' I - r,.;... t
CONNECTION DATA
ADDRESS
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CITY yr. �° TEL. NO,
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MANHOLE.REFERENCE
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c-< STATE '�_ -" - Ji� GOWER r'
NOGISTRADESCRIPTION OF Oj Y couNTv
---- - ---- - ---- TYPE OF CONNECTIO1,I,. LENGTH FROM
HOUSE SEWER CONNECTING TO f Y. CURB P I M.L.TO P.L.
_PUBLIC SEWER @- $ <t
- SEPTIC TANK.SEEPAGE PIT OR — IY
I PITS AND/OR DRAINFIELD @ $3.q0 ---_—_—.--- —�.-- —_--_. ._—. --
OVERFLOW SEEPAGE PIT,DRAINFIELD ! y P C N0.
EXTN.,CESS POOL.DRYNELL,MANHOLE (a! $2.001 CC. IMP. N0. F JOB N0:
--� HOUSE SEWER CONNFCTSNu TO i
PRIVATE DISPOSAL SYSTEM CTI $1.00 TRUNK PERMIT NO _ ROAD PERMIT NO.
-_-'�- CONNECT ADDITIONAL BLDG.ORI
' STATE ENCROACHMENT
T� WORK TO HOUSE SE MER @ $1.00 PERMIT_ NO.
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM? (iu $1.00 INDUSTRIAL
.— —_— --_.-_--_ WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT � _ t 00 ----- ------------
AUTHORIZATION TOTAL FEE � 1 -- REIMBURS;EMENT FEE
APPROVALS DATE �INSPECTOR'SSfGNATURE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- -.--_—__ ..------J_-.._.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING j
TC 'HE PUBLIC S ,
E `ER. "i NEW HOUSE SEWER
SIGNED THIS DAY OF ' --- ------- �J
.v ,9=.� CONNECT ADDITIONAL _—- ---- --
OWNER OR f,. " - BUILDING OP, WORK ----------- ---- .__—
OWNERS AGENT -. �;vq -- _ _.._ .—
„ _F� SEPTIC TANK SEEP;PIT(S)
AD ES5-- �"`'�'�'�`F"'+%�_i✓`y'�_ _h "- �-- AND/OR DRAINFIELD
-- I HEREBY ACKNOWLEDGE TH.AT..I-HAVE READ TH15 APPLiCA N CESSPOOLu DRYVdELL[]---- _—
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO CO LY --__. _
WITH ALL COUNTY ORDINANCES AND STATE, LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS, SEWAGE DISPOSAL SYSTEM I i
I HEREBY CERTIFY THAT 1 AM PROPERLY ED AND,'OR —
LICENSED AS REQUIRED BY LGS ANuEE,ES G TY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA..OR 'THAT I.AM THE LE'' L WN€R OF T.£ ABOVE ABANDON HOUSE SEWER
DESCRIBED-RESIDENTIpt. PROPERTY BACKFILL SEPTIC TANKSI1
SIGNATURE C ' SEEP,PIT(S) L1 CESSPOOLSC
OF PERMIT? '� `�d=` L• `. ;'^ t' :�_.
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JOHN A.LAMBIE,a NTY ENGINEER . ALII)ATIOROBERT A,WOOD, CHIEF PLBG. INSPECTOR
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61. B. CASH