HomeMy Public PortalAbout5835 PRIMROSE AVE_Sewer__ 'eAg" D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County �®er Fn ADDkESS � �y
'
CASSATT D. GBffFM, Sup't of Building LOCALITY
NEAREST "e..r-"'v"�.�-�.'•:'
FOR APPLICANT TO FILL IN ---� CROSS ST. -
LEGAL
DESCRIPTION LOT OWNER
BLOCK TRACT _ " MAIL pv
ADDRESS / '3
NO. 0 BLDG$. °
SIZE OF LOT s' 3 NOW ON LOT CITY •TEL.NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
BK. PG
.CONTRACTOR
ADDRESS , wd CONNECTION DATA—Y
"CITY TEL.NO. j°l :,S' STATION DEPTH
"b
STATEMANHOLE REFERENCE UPPER
REGISTRATION NO. / ;'� �' i' ❑ COUNTY �,
NO. DESCRIPTION OF WORK FEE
HOUSE SEXIER CONNECTING TO
PUBLIC SEWER @ $3.00 � ��` � TYPE OF CONNECTION fir" LENGTH FROM
SEPTIC TANK, SEEPAGE PIT OR T. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINF'IELO $3.00 v 'r
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE 0 $2.00
I HOUSE SEWER CONNECTING TO P.C.N0,
f PRIVATE DISPOSAL SYSTEM @ $1.,00 _CO3 IMP,NO. , ,y g�'. JOB N0, _
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT NO.
WORK TO HOUSE SEWER $1.00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT•
5EWER OR DISPOSAL SYSTEM C $1.00 PERMIT N.O.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER`S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. — APPROVALS DATE QINSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER,
SIGNED THIS DAY OF 19— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL - -
OWNERS AGENT._ 'i BUILDING OR WORK
SEPTIC TANK,SEEP,PITS)
ADORES S AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS. CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL C❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAp I THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDEN AL OPERTY. p BACKFILL SEPTIC TANKS El
SIGNATURE �� � ' SEEP.PIT(Sj ❑ CESSPOOLS
OF PERMITTE
mmilwim
bF VALMATION ROBERT A.WOOD
et[, M.o. CASH SUPERVISING MECHANICAL ENGINEER
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