HomeMy Public PortalAbout6114 PRIMROSE AVE_Sewer__ GA a-sg°
EoAPPLICATION FOR PERMIT
E608 COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BuiLDING ✓W� "
IOHN A. I.AMBIE. Count Engineer ADDRESS
CASSAT"T D. GRIFFIN, Supt of Building LOCALITYNEAREST
FOR APPLICANT TO FILL IN
ROSS ST.
bESCRGALD �TLOi N0. OWNER
BLOCK TRACT MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF a;
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED IIYy'
r BK PG i
CONTRACTOR P _ I -
7 1
ADDRESS CONNECTION DATA
CITY Rg ✓ TEL.N0.- STATION i, DEPTH747
8-1"
AT£ MANHOLE REFERENCE UPPER
REGISTRATION NO. ty COUNTY LLOWER
NO. 1 DESCRIPTION OF WORK FEE
HOUSE SEWER.CONNECTING TO -
PUBLIC SEWER. @0 $3,00 f TYPE OF CONNECTION LEh1GTH FROM
SEPTIC TANK,SEEPAGE PIT OR ;Y� CURB P.L. M.L.TO P.L.
PIT$$AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EX"TN..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.N0.
_ PRIVATE DISPOSAL SYSTEM @ $1"00 _CO.".IM.P�No. JOB NO.
CONNECT ADDITIONAL.BLDG.OR
WORK TO HOUSE SEWER $1.0Q
TRUNK PERMIT NO. ROAD PERMI7.Nd '
C:)
Af_TER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT '
SEWER OR GIsPOSAI_SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL -
CHARGES
OVMER'S PERMIT $ 1 2( 0® CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE I REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
70 THE PUBLIC SEWER,
SIGNED THIS—DAY OF )9— NEW HOUSE SEWER
OWNER OR
OWNERS AGENT—,-02--'c'&/-- CONNECT AO
BUILDING OR WORKAL
WORK
ADDRESS SEPTIC TANK,SEEP,PIT(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 El
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTF.R,REPAIR,SE1VER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AN—. -DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AMO
M HE LEGAL OWNER. OF .THE ABOVE
DESCRIBED RE$IDENTjAL POPIATY, ,' - BACKFILL SEPTIC TANKS
SIGNATURE !, SEEP,PIT(S) ❑ CESSPOOLS [�
OF PERMITTEE i -
DATIOm ROBERT A. WOOD
CK. X.Q_ 7-CASH SUPERVISING MECHANICAL, ENGINEER
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