HomeMy Public PortalAbout5915 PRIMROSE AVE_Sewer__ 'E808
,2-68 APPLICATION FOR PERMI
76A 642)
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUIL NG 1� e"-sz
JOHN A. LAMBIE. COUNTY ENGINEER ..ADDRESS v z
COLEMAN W. JENKINS. SUPT. OF BUILDING
LOCALITY x
NEAREST 7
FOR APPLICANT TO FML IN C R FOSOS IS ST. ii
LEGAL
DESCRIPTION
CRIPTION.. LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS A,
�7, A :—
NO. OF SLOGS,
0
SIZE OF LOT NOW ON LOT CITY 10 kl 4-4- TEL. NO.
USE OF
S
BUILDINGS DISTRICT NO. GROUP MAP qPROCESSEDBY
-� / A'� A '4K PG
CONTRACTOR
ADDRESS 4.
je� L/ CONNECTION DATA
CITY110. STATION DEPTH
STATE' LIC > L-x ll��
LICENSE NO, 4 It LASS Cl- MANHOLE REVERENCE )lei LOWER
No. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FIR
0
T HOUSE SEWER CONNECTING TO Y CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $S'00 P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR JOB No.
@ $10-00
�PTS AND/OR DRAINFIELD CO.IMP. NO.
'40 'E SEWER CONNECTING TO TRUNK PERMIT NO,
�PRIVATE DISPOSAL SYSTEM @ $3.00 ROAD PERMIT NO.
-kV
.i�4.CfADDITIONAL BLDG.OR AFFIDAVIT I A ifjWAI STR.N . DATE
��Oeljl<TO Hll'JSE SEWER E3.00
L. SEEPAGE PIT.DRAINFIELD _IRECORD.INSTR.N
EXTNC!�-,SPOOL.DRYWELL.MA NH OLEO $5.00
j
HWY.OR ST.WIDENING ANP111110,1REVAIR OUSE L,
SEWER dW=MNlbMW4AQF�TEM @ $3.
STATE ENCROACHMENT
PERMIT NO. cn
INDUSTRIAL
WASTE APPROVAL
OWNER'S [PERmrr 27oo CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I HAVE: AT rNAMED DATE A CONTRACT WITH THE HEREIN ND C N- REIMBURSEMENT FEE
TRACTOR TO-CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE I SIGNATURE
SIGNED THIS DAY OF 19--
OWNER OR NEW HOUSE SEWER
OWNERS AGENT-
CONNECT ADDITIONAL
BUILDIN
ADDRESS G OR WORK
I H EREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK.SEEP,PIT(S)
ANO/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITHL'AL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL [3 DRYWELL ❑
IHER HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTE EWEROR
LICENSED AS RE4LJ!RF.0-ITYJOS ANGLES COUNTY-)ANDkSTATE, OF SEWAG POSAL SYSTEM
CALIFORNIA OR THAT-I AM THE V4AL C)A)VNC;R DISCONNECT PLUG AND
RESIDE IN, THE ASIOVE"bEVCRIB 91 4wmt'At ABANDON HOUSE SEWER
SIGNATURE
OF PERMrtTEE - 77 BACKFILL SEPTIC TANKS El
SEEP,PITHS) 0 CESSPOOLS 0
VALIDATION JACK R. ALLEN
CK. M.0. CASH SUPERVISING MECHANICAL ENGINEER
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