HomeMy Public PortalAbout5952 PRIMROSE AVE_Sewer__ > E-66
& APPLICATION FOR PERMIT, ",,f
S&E-669 9.55 r'r
DIVISION OF BUILDING AND SAFETY SEWER--SEWA DISPOSAL.
Department of County Engineer
County of Log Angeles FNEAREST
1
WM.J. FOX. COUNTY ENGINEER
� 8
CASSATT D.GRIFFIN,SUPT OF BUILDING
FOR APPLICANT TO FILL IN
LEGAL.
DESCRfPTION LOT NO OWNER
BLOCK TRACT ,;�. _— MAIL
ADDRESS -
NO. OF BLDGS. ----- _. .----- - -- --
_.SIZE,_.OF LOTS- . ~. ONOW ON LOT CITY TEL. NO.
USE.OF
BIA i)INGS _ .,- �-?`- } DISTRICT NO, GROUP MAP
BK PG
CONTRACTOR
_
ADDRESS ----- -- CONNECTION DATA
.—CITY STATION
TEL ° DEPTH. --
:.... ❑ STATE MANHOLE REFERENCE1.�, -- __UPPER_
REGISTRATION NO. _____. _._T,:.y
No_J DESCRI.PTIOIY OF',WORK FEE _ -` ---- -- ---.---- —. _ — - .—
- --- .-- TYPE OF CONNECTION LENGTH FROM
HOU:.E SEWrR CONNECTING TO M !. �0 P L.
pr
1__�_ PU3LkC 5-WER _ r� $ 8.501 a:i> v_ .✓ - ----- --- _ _
HOUSE SEVER CUNNr�TiNG'IO —.. ._
1
PRIVATE DISPOSAL SYSTEM 1.60 _ I _ --- �•�y� � r -- �" y=ip:
CONNECT T ADDITIONAL BLDG. OR {IJ— a P C NO.
13—LWORK TO HOUSE SEWER f.00! - - CO. IMNO.}S _, _JOB N0.� J.........
ALTER OR REPAIREStr — '— - TRUNK PERMIT NO. - yP0AD PCR;, T t0. --�--
SEINE- OR DISPOSAL
SYSTEM
STEM ECO'
]DISCONNECT AND APANDON SEWER STATE ENCROACH;p ENT
— —ANO!OR DISPOSAL iST_N__— 1.00 .—� PERMIT NO
SEPTIC TANK, SEEPAGE PIT OR .--------..--
PITS AND/OR DRAINf'IELD <.CO� INDUSTRIAL
CESSPOOL- DRYWELL V,P,S rE APPROVAL
SPECIAL CONDITIONS ONLY - 2.00 CHARGES
AUTHORIZATION
.I1VOWNER'S 00
AEIIMIT �� CONNECTION CHARGE FEE —�— �-- ---T,---
6'Y,t+� .5zj4,C1TI6J6`1 TOTAL FEE
I � REIMBURSEMENT FEE
-1 HAVE THIS DATE CONTRACTED Vd1TH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DEESC- UoED EXiS„NG D vELLING APPROVALS DATE
- 1 �INSPEC OF SSIGN.ATU
RE
TO THE PUBLICSEWER � — ----- _I
SIGNED TNiSamiDAY OF _NEW HOUSE SLVER
-. CONNECT ADDITIONAL
OWNER OR
OWNERS AGENT BUILDING OR WORK
_ SEPTIC TANK, SEEP, PIT(S)
ANDiL'R DRAINFIELU____ _-
i HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL O
AND STATE THAT THE ABOVE 15 CURRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR ...-�r
PLUMBING AND SEWERS. __ALTER REPAIR,S ER Eli
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/CR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF J
CALIFORNIA OR THAT I A14 THE LEGAL OWNER QF` THE ABpVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. :' BACKFILL SEPTIC TANKS C_,
SIGNATURE' ..SEEP. PIT(S) C] CESSPOOLS U
' OI ,r ”"
OF PERMITTEE i !I
WILLIAM J,.-FpX,COUNTY ENGINEER VALIDATION R.A.WOOD.CHIEF PLBG. INSPECTOR