HomeMy Public PortalAbout5831-5833 PRIMROSE AVE_Sewer__ exenaa APPLICATION FOR PE F IiIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION cull WING
TORN A. LAMBIE, County Engineer _
CASSATT D. GRIFFIN, Sup't of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN cROSS ST. -- -
LEGAL / Y - ry
DESCRIPTION LOT NO i L I OWNER *°
BLOCK TRACT % J/ MAIL
ADDRESS �a�✓ e ^
N0,OF BL.DGS. _
SIZE OF LOT NOW ON LOTS CITY TEL. NO.
USE OF
DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTORADDRESS ? a _ CONNECTION DATA
CITY TEL.NO. STATION DEPTH
C) STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. _ [] COUNTY LOWER
NO. DESCRIPTION OF WORK FEE _� -
HOUSE SEWER CONNECTING TO _TYPE OF CONNEC ION LENGTH$3.00
PUBLIC SEwcR 'F
=ROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P,L.
PIT5 AHD/OR DRAINFIELD C $3>00
OVERFLOW SEEPAGE PIT. DRAINFIELD
EXTN..CESSPOOL,DRYWELL $2,00
HOUSE SEWER CONNECTING TO P,C.NO.
PRIVATE DISPOSAL SYSTEM $1.00 CO.IMP. NO. SOB NO. -
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER C? $1.00 TRUNK PERMIT N0. ROAD PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE c ATE ENCROACHMENT -
SEWER OR DISPOSAL SYSTEM n $1.00 PERMIT NO.
r I INDUSTRIAL
_.' V,ASTE APPROVAL
3
' t CHARGES
OWNER"S P_RMIT 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE a REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS i DATE _INSPECTOR'$SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS— DAY OF1�_ __ NEW HOUSE SEWER
OWNERSOAGENr ¢ r ' CONNECT ADDITIONAL
d- BUILDING OR WORK
ADDRESS, SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINPIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT.THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL 0 DRYWELL CJ
WITH ALL COUTY ORDINANCES AND STATE LAW'S REGULATING -
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ATE OF DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT � AM THE LEGAL OWNER OF THE ABOVE
DESCRIBE RESIDE TI PROPERTY. " i .> BACKFILL SEPTIC TANKS []
SEE,P,PIT(S) [! CESSPOOLS
SIGNATURE
OF PERMITTE
)� VALIDATIOPF: ROBERT A. WOOD
CK. R.a. F CASH SUPERVISING MECHANICAL ENGINEER