HomeMy Public PortalAbout6327 PRIMROSE AVE_Sewer__ :E.ciOfl 3-62 ;�sl�f
0A64ZD APPLICATION FOR PERMIT/
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
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JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Supt of Building
! LOCALITY
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NEAREST
FOR APPLICANT TO PILL IN CROSS-T- ' -- '----.---- ------------
LEGAL
r,E S C R I PT 10 1,OT NO r OWNER
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BLOCK TR.AC I, t.'y i<--.� � ADDRESS -
NO. OF Bt DGS.
SIZE OF LOT o ON t..OT CITY TEL- N0.
L = OF
BU7LDtNGS DISTRICT NO GROUP .a,P _ PROCESSED BY
CONTRACTOR
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ADDRESSLd +� '• .. a ,, , .w. _ CONNECTION DATA
STATION -.... DEPTH
CcITY. k"ate, - TEL Kb.
A TATE
MANHOLE REFERENCE
REGISTRAT ION Nq - s i COUNTY i 'L.OWCFi _
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH Ffi Opt w
Dl. E sEW ER CONNE TING TO j ,,•:.;. Y. _ CURB P L M..L TO FiYL. ZA.
$5.00 _ _
�3 ,c.
'PU BL 3E.SEWER. Ca '}., I __ - ._ _ _ _---__
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SEPTIC TANK,SEEPAGE PiT OR I / .:.
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PIT. AND/OR DRAINFIELGO".IMP NO. -- - - '
HOU ESEWER CONN CTl N.a 7O TRUNK PERMIT NO ROAD PERMIT NO. - ///�qqq
PRIVATE DISPOSAL SYSTEM
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C,CNNE ADD JN AI BLDG-7R AFF(DAV T WAIVERCASEMEtt kLCbRD .NS'}-t No. DATE
ti WORK TO HOUSE SEWER R @ $3.00 � - ! U
O4 FRFl OA! F£.FAUL PIT,RRA NFIET..D
EXT N.,CESSF jOL,ORYWEt_L,.MA NNOLE @ $5.(T0 i
-.rA(R OR
,A _ -__ABANDON HOUSE HVr Y.OR ST.WIDENING..
LTER.R I _
SWEri R O015 P05 AL SYS TEAS .$3.00
-. .__ _ STATE ENCROACHMENT .�
I PERMIT NO. -
_-._..__i. INDUSTRIAL
WASTE APPROVAL
OWNtR�? PERMIT - CHARGES
_ ' 9O _...-.____ -.—. _ .—_._ —_�—
_._ CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE
HAVE AT THIS DATE A CONTRACT WITH THE F(EREIN NAMED CON- RE'MBURSEMENT FEE
TRACTOR TO cnONNECT THE. ABOVEDESCRI13F_O EXI.ST.INQ DW�I...L.cNGg)-
TO THE PU BL pt; SEWER. APPROVALS DATE IN PE�CTOR 5 SIGNATURE
SiGNEt? THIS---DAY OOF.------19-9—
_APPROVALS ..--.____i ,.- .--_,._.__
O tNNFR O t 3 a,_.� NEW HOUSE SEWER
OWNERS A%EN __ � '*-Y -- -
'a- --- - CONNECT ADDIi'IONAL
BUILDING OR WORX V
-
SEPTIC RAMI,SEEF PiT(S) I t
'r HEREBY ACKNOWLEDGE THAT 7 HAVE READ THIS A.PPL.I'A'TYOItl AND'OR gRAINFIEL.D I
A. S. :TF_ T:t.AT THE AF;OVE IS CORRECT AND AGREE TO COMPLY
WITH A.LI- CO N 'Y ORDINANCES AND STATE LAWS REGULATING 9 !
PL UMBfNG AND SEWERS. CESSPOOL ❑ LRYWELL. ❑ j -
i HEREBY CFRT-V T'HA'T I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR l--t-_�-- —A-_--
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE. OF SEWAGE DISPOSAL SYSTEM j
CA LI'.F ORNI! OR 7HA7 } AM 7HE LEGAL OWNER OF, AND INTEND TO DISCONNECT PI_l G AND--�'---
RESIDE IN, 'T FIC ABV C1EoL:RIB£D FEN>ETI?_ PROPERTY, -- ----
a'{ ABANDON HOUSE SEWER
SIGNA LREa� v f e HA.,.KFit_SEPTif AN3t5 ❑--J-�J_ --rv_--�
OFf-EP,MITT'EE Y° _ q, '�`Y�y- i SEEP,PIT(S) CESSPOOLS []I I
VALMATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M..O. CASH