HomeMy Public PortalAbout9122 PRIMROSE AVE_Sewer__ '6A642D61 APPLICATION FOR PP-RMIT '
COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER -
BUILDING AND SAFETY DIVISION BUILDING j '
JOHN Ap LAMBIE, County Engineer ADDRESS fit
d
WILLIAM A. JENSEN, Supt of Building LOCALITY
NEAREST0FOR APPLICANT TO FILL IN CROSS ST.LEAL
DESCRIPTION LOT N0, OWNER
BLOCK TRACT f � I � MAIL
ADDRESS
N0.OF BlLDGS.
SIZE OF LOT NOW ON LOT CITY TEL, NO
USE OF
BUILDINGS DISTRICT NO. GROUPMAP PROCESSED BY
CONTRACTOR i BK P6 ` o
ADDRESS d�j4q e CONNECTION DATA
EL.N0. STATION DEPTH
STATE REGISTRATION NO. 6 c9 ga.� $�' C
NO. DESCRIPTION OF FEE:�� � OUNfY MANHOLE REFERENCE UPPER
LOWER
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPIVOF CONNECTI LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. 6URB P,L. M.L.TO P.L.
PITS AND/OR DRAINFIELD $3.00 _
OVERFLOW SEEPAGE PIT,DRAINFIELD f'' y.
EXTN..CESSPOOL.DRYWELL @ 52.00 p.
PRIVATSEWER
6 S OSALSYSTEM TO @ SLOO CO. NO. JOB NO, O
V
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0.
WORK TO HOUSE SEWER (� St.00 ix
SEWER OR 6A5PdSAL SYSTEM HOUSE $1 00 STATE ENCROACHMENT
PERMIT NO. ri
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 7 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'SSIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS D Y OF i9_____ NEW HOUSE SEWER
OWNER CONNECT ADDITIONAL
OWNERSAGENT
AGENT BUILDING OR 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
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 9 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE-LEGAL OWNER OF THE ABOVE BACKFILL SEPTIC TANKS DESCRIBED RESIDE TIAL PROPERTY.,
SIGNATURESEEP,PIT(S) CESSPOOLS
OF PERMITTE
1- vALIDATION ROBERT A. WOOD
cK r.0, CASH SUPERVISING MECHANICAL ENGINEER
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