HomeMy Public PortalAbout6003 RENO AVE_Sewer__ ----.
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APPLICATION FOR PERMIT /
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP MAP PROCE E{)BY
oe i,BUILDING -
ADDRESS + L d"-.7, )_J 4_
CONNECTION DATA
LOCALITY "`
,NEAREST �. STATION ,I( DEPTH
CROSS ST. f
�Y UPPER
_ MANHOLE RE FERENCE�°(,1.4>- •Y OWER
'OWNE - �� - �` TYPE OFC CTION LENGTH FROM
MAIL �W Y. CURB P.L. M.L.'TO P.L.
ADDRESS /T� ,
77 P.C.NO.
CO.IMP.NO. �S�j JOB NO.
CITY TEL.NO. --.�`
LEGAL � f / J TRUNK PERMIT NO. ROAD PERMIT ,g
'DESCRIPTION LOT NO.e^� k-. ` ter ? !6`
AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT f:
NO.OF SLDGS.
SIZE OF LOT- NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDING �. ?'^ m?"T��yAx'a STATE ENGROACH,j6ENjT
PERMIT NO. _
�r INDUSTRIAL
CONTRALTO WASTE APPROVAL
ADDRESS CHARGES
CONNECTION CHARGE FEE
STATE LIC, - REIMBURSEMENT FEE
LICENSE NO. � �.� CLAj(; -�
NO. DESCRIPTION OF W RK FEE APPROVALS DATE INS P CTS SIGNATURE (�
HOUSE SEWER CONNECTING TO
PUBLIC SEWER ^^��
SEPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER .f` .../; 0
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK ffffYYYY
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG.OR SEPTIC TANK,SEEP,PIT(S)AND/OR DRAINFIELD Z
WORK TO HOUSE SEWER r
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL ElDRYWELL❑
EXTN..CESSPOOL.DRYWELL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑
SEEP.PIT(S)❑ CESSPOOLS❑
OWNER'S Permit S z
AUTHORIZATION TOTAL FEE VALIDATION
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TOCONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLICSE WER.
SIGNEDTHIS DAYOF 19
OWNER OR
OWNERS AGENT - -
ADDRESS
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
I HEREBY C$RTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNI OR THAT I AM THE LEGAL OWNER OF,AND INTEND TO RE-
SIDE IN TH ABOVE DESCRIBED RESIDED{,T/f P �'E
IAL RTY.
S IG NATU RE�z4 �
f. t,
OF PERMITTEE`'`--