HomeMy Public PortalAbout5751 RIO HONDO AVE_Sewer__ 76 A 16,12 0
E-66it 3_55 APPLICATION FOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Depaximent of County Engineer
County of Los Angeles BUILDING
WM.J.FOX,COUNTY ENGINEER _
ADDRESS
CASSSUPTTT D.GRIFFIN, SUPT OF BUILDING LOCALITY
fOR APPLICANT TO FILL IN NEAREST A,
'ECAL —-----
DE
.LOT.NO., OWNER
TRACTMAIL
NO. OF BLDG$.
SiZ_'E OF NOW ON LOT CITY
LOT NO.
USE OF
DISTRICT 0.
GROUPMAP
SK -PG
CONTRACTOR
ADDRESS >> CONNECTION DATA
CITY STATION DEPTH
STATE MANHOLE REFERENCE -------UPPER
REGISTRAT;ON NO,
COUNTY ......
Im.] D;_-SCRIPTION OF'WORK FEE
TYPE
W
ER CONNECTING TO �4ECTION LENGTH FROM
HOUSESE
PUBLIC SEWER $ 3�5'0
P,L. W.L. TO P,L.
HOUSE SEWER CONNECTING TO
—PRIVATE DISPOSAL SYSTEM 1-00
CONNECT ADDITIONAL BLDG. OR P cNO.
WORK TO HOUSE SEWER 1.00 CO. INIP. NO —'OB No,
ALTER OR REPAIR EXIS :NG.
SEWER OR DISPOSAL SySrEM 1,00 TRUNK PERMIT NO. ROAD PERMiT NO.�4
DISCONNECT AND ABANIjON SEWER STATE ENCROACHMENT
ANOR DISPOSAI.SYSEV' 1,00 PERMIT NO,
CT_ TRIALi _ INFIELD INDUS
ESSPO � ASTEAPR
OVAL L
_5:�-LS;IAL CONDITIONS ON LY 2.00
CHAR'ES
CONNECTION GEF EE
OWNER'S 5 11 00
TOTAL FEE REIMBURSEMENT FEE
AUTHORIZATION
I HAVE Tf, N1SDAr_E CON-,"RACTED WI_NTHEDPKR',fN NAMED CON-
TRACTOR ONECT ,HE ABOVE DESCRISE, EXISNG TIDWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO T!qE PUBLIC SEWER ......
NEW HOUSE SE1,A.,EP
SIGNED THIS �_GAY
OWNER OR CONNECT ADDITIONAL
OWNERS AGE'NBUILDING OR WORK
SEPT!C TANK, SEEP, PIT(S)
A _
DDRESS=__.__.
AND/ R IDRAINFiLLD
I HEREVY ACKNOWLEDGE THAT I HAVE READ THIr APPLICATION crssvooLo rmwai,C]
AND S THAT rHE Ab.VE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUIMBiNG AND SEWERS. ALTER,REPAIR,9EWER OR
SEWAGE DiSPOSAL SYSTEM
CER.T'IFY THAT I AM PROPERLY REG)STERED AND
T PLUG AND
LI,EN3E:b As RCQU'RED BY LOS ANGELES COUNTY AND STATE 0 DISCONNEC
CALIFORNIA OR THAT I- AM THE LEGAL cvn4r_R OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENYA''PROPEFTY. BACKFILL SEPTIC TANKS El
SEEP.PIT(3) C'ESS POOLS
SIGNATURE
OF PERMMEE
L
WILLIAM J.FdX.CouNTY E-NaL.mr-ER VAMATION R.A.WOOD, CHIEF PLEG. INF51PECTOR