HomeMy Public PortalAbout5929-5929 3/4 PRIMROSE AVE_Sewer__ 7&E-GCS3 f2:E4
& APPLICATION FOR PERMIT
S E.G C-
DIVISION OF BUILDING AND SAFETY SEWER-SE-WAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
WM.J. FOX. COUNTY ENGINEER ADDRESS - _ --
CASSATT D. GRIFFIN. SUPT OF BUILE)!NG LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL --
DESCRIPTION LOT NO. _ OWNER
BLOCK TRACT MAIL ---
- ADDRESS
N0.OF BLDGS.
L,,7' O _—.
SIZE GF w_ ^. N `,h' ON LOT CITY TEL. NO.
USE OF
LO -O -_._.�
BUILDINGS
_ CT NO. GROUP j M,AP
UIL - +I
CONTRACTOR BK PG
_.
ADDRESS CONNECTION DATA
CITY TEL.. NO. STATION DEPTH
❑ STATE _ MANHOLE REFERENCE
REGISTRATION NO. _ J COUNTY UPPER �I.O`XER
��---'-------'�--'-`-`-- -" TYPE OF CONNECTION LENGTH FRO'r'.'
NO. I DESCRIPTION OF VIORK FEE _Y• _ CURB P.L. M.L. TO PJ_
--I
HOUSE SEWER CONNECTING TO �-
PUBLIC SEWER _ 011 $
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL YS'FEf9_ _1,110
CONNECT,(DDITION4L BLll G. OR CO. IWIP. NO, dOB. NO.
WOPM TO HOUSE SEWER 1.00 1 ..- ,
.ALTER OR REPAIR FX,STING PERMIT N0
TRUNK PERMIT NO. ROAD .
A SE.E: OR DISPOSAL SYSTEMS 1.00 i
DISCO.'JNF 1 A.ND BANDON SEWER RO _._._
AND/OR D!SPCSAL SYSTEM 1.00 _ STATE ENCROACHMENT
SEPT; PERMIT NO
C TANK. SEEPACE PIT OR �
T
PITS AND/OR DRR NFIELD 2.00_ !NUUS7RiAL
CESSPOOL DRYG ELI L APPROVAL
SPECIAL
-- —.. �—' -----
SPECIAL CONDITIONS ONLY 2.00 I CHARGES
PEItItiiiT CONNECTION CHARGE FEE
AUTHORIZATION ITOTAL IEE -�- j rFTMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- APgI�®$�� DATE 1NSPLCTORSSiG.NA7URE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING D� c1,! ham.-
TO THE PUBLIC SEWER - _'�' ---"--'--I--"-- -- -i-
NEW HOUSE SEWER
SIGNED THIS- DAY
OW NF'R OR CONNECT ADDITIONAL
__ R WO _ _
OWNERS AGENT BUILDING ORK
SEPTIC TANK, SEEP, PIT(S)
AND/ORDRA!NFiELD _
I
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL[I
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING �ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
i HERESY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR --..�-----'--�`— ----- - "��"'.
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND-STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL. OWNER OF THE ABOVE ABANDON HOUSE SE'J/ER _
DESCRIBED .RF$IDENT!AL PROPERTY.. �BACKFILL SEPTIC TANKS CI
SEEP,PIT(S) [J CESSPOOLS❑
SIGNATURE ____._..,..._....�._,_�....�.� _
—
OF PERMITTf-E._.
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
s,
eTOB`Ju I $ 4 2.00
DEPUTY DEPUTY
BY BY
p DEPUTY DEPUTY