HomeMy Public PortalAbout5834 PRIMROSE AVE_Sewer__ EaOa 2/7C .
;6A 6A2.D APPLICATION FOR PERMITp ,2 .� __
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY,DIVISION BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
COLEMAN W. JENKINS, SUPT. OF BUILDING Y_
LOCALITY
FR
APPLICANTNEAREST TO FILL IN CROSS ST
I.P R I N T OR TYPE ONLY 1 _ -- ---7BLOCK
_ LOT NO - OWNERMAIL
TRACT - ADDRESSNO. OF SLOGS.
NOW ON LOT CITY" TEL. NO.
USE OF
BUILDINGS Disi RICTNO. GRO.UP., CLASS MAP PROCESSED BY
SK
CONTRACTOR
I.
ADDRESS - CONNECTION DATA
CITY TEL. NO. STATION DEPTH
STATE ''` �—^LIC MANHOLE REFERENCE '�—
LICENSE NO. - - CLASS - _r, f r/r� LOWER
NO, DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTFX'FROM
HOUS£SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00 —
_..__.— P.C..NO.
SEPTIC'SANK.SEEPAGE PIT OR CO. IMP. NO. JOB NO.
PITS AND/OR ORAINFIELD @ $f0.00 _ ---.------ — —
HOUSE SEWER CONNECTING.TO TRUNK PERMIT NO. ROAD PERMIT NO. �-
PR V.ATE D SPOSAL SY TEM $3.00
CONNECT AOD;TIONAL BLDG —� AFF?DAVIT wAIY[R -EA5[MEur RECORD.YN5TR.NO. .DATE
WORK TO SEEP 6EF;I � $3.00 _ —� � `--_
OVERFLOW SE£PAGE P 7,DRAIN FIELD
EXTN.,CESSPOOL.DRYWELL.MANHOLE 55.00
ALTER.ftEPAw
_ _iR OR ABANDON HOUSE_—__._.___. HWY.OR ST.WIDENING. 0
.SEWER OR DISPOSAL SYSTEM 53.00 ---`" WC €.-
___ -._________.-_._..__._�__.—_ STATE ENCROACHMENT E.J
PERMIT NO. _ LU
INDUSTRIAL LL
WASTE.APPROVAL
OWNER'S PERMIT ffi -::2 oo ---------CHARGES - -
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE - --
I HAVE .ATTHIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR T0C ONNECT THE ABOVE DESCRIBED EXISTING DWELLING - - ' —--
TO THE PUBLISEWER. APPROVALS DATE INSPECTORS SI GNAT:URE
SIGNED THIS DAY OF--19—
OWNER
F99—OWNER OR NEW HOUSE SEWER ~
OWNERS AGENT-
CONNECT ADDITIONAL
BUILDING.OR WORK
ADDRESS____.
SEPTIC TANK,SEEP,PIT(5i I -
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 1S CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLU M RING AND SEW RS. CESSPOOL ❑ DRYWELL ❑ I __` -
I HEREBY CERTtPY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT i AM THE LEGAL OWNER OF'AND INTEND TO DISCONNECT PLUG AND
RESIDE 1N.. THE 1EOVE DESCRIBED HESf.DEN7IA ,PROPTY. ABANDON HOUSE SEWER
S+GNATURE -std ,$y,, ev- BACKFILL SEPTIC TANKS ❑
OF PER MTTTE E; yy"ra� _: -_„(� — SEEP.PIT(S) ❑ CESSPOOLS ❑ +
1
VALIDATION'_ JACK R. ALLIEN
SUPERVISING MECHANICAL_ ENGINEER
CK. M.O. CASH