HomeMy Public PortalAbout5505 ROBINHOOD AVE_Sewer__ "A*"D•\H NW■ APPLICA"T"ION FOR PERMIT _ 1
DrvmoN OF tummw mo SAFm SEWER--SEWAGE DfSPOSAL
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ING
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CASSATT D.GRIFFIN,SuwV oY NuasWY ITY
FOR TO M IN
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Dlca Pr1olt Lor NO. , OWNER
BLOCK TYACT ZklJAIL
ADDRESS
SIZE N0. OF DLDGS.
OF LOT �y!� XQW O!1 IAT CTTY
USE OF
BUILDINGS DISThICT NQ, GROUP OAP
P7
COkYRACTOR
ADDRESS CO! M(MON DATA
CITY. TEL. NO. 4 JTA'IION DEPTR
f B STATE MANHOLE REF EN UPPER
REGISTRATION NO. f�y Z 2 ElcOUNYYOWER
N0. DESCRIPTION OF WORK FEE 2t A4, 47
TYPE OF XNECTIO
HOULIC FEWS rWER a.bo Y. M.L.EX H FROM
-
PUBLIC
CO (♦ECTING TO YCURB P. .L. TO-P.L_
PUBLI
HOUSE EWER CONNECTING TO
PRIYRT>g DISPOSAL SYSTEM 1.00
rECT ADDITIONAL BLDG.OR Cp. imp. t10. JOB N O
WORK TO HOUSE SEWER 1.00
ALTER OR 7PAIR EXISTING
SEWER OR b13POSAL SYSTEM 1.00 TRUNK PERMIT X0. OAD PERMIT NO.
DISCONNECT AND AAN $TATE ENCROACHM
DD SEWER ENT
AND/OB DISPOSAL A. 1.00 EITAT IT N0.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/O DRiSIXFtELD 00 INDUMI
CESSPOOL-DRYWELL PAL �
SPECIAL CONDITIONS ONLY 2.00 CH RGES
aVnfws PERMT s 00 CONNECTION CHARG[FEE
AV laoR=TION TOTAL REIMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH TAE HE�RREEIN NAYHHpp CON- =n
TRACTOR TO CONNECT TAE ABOVE DESCRIBED 9ElffTING DY<EI,LIN-G "PROVA S DATE INSPICTOR'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS SAY OF 19-
NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGEr('I- _ BUILDING OR WORK
IX10C'TANK,BEEP, PIT(a)
ADDRESS AILD OR DRAI NFIILLD
I HEREBY I^�CII((NOWLEDCE THAT I HAVE READ THIS APPUCATJOR CESSPOOL❑ DRYWELL❑
AND STATE TI{AT THE' ABOVE IS CORRECT AXD AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AHD STATE LAWS REGULATING REPAiR,SEW7=R OR
PLUYBINQ AIiD SEWERS. SSWAAG DISPOSAL SYSTEM
1 +IFREBY CERTIFY THAT I AN PROPERLT REGISTERED AkD/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG ANp
CALIFORNIA OR THAT I AM THE LEGAL OWN dl< THR ABOVE ABAN- ON HOU SEW
DESCRIBED RIGS AL PROP
BACKFILL1 CESSC TANKS❑
BEEP.PIT POOLS
SIGIIATURE
OF PERY1TTE
WII r Inu OX. uNY NGIIR R.A.WOOD. Cmor FLmo. INsa�ToIR Ya
I 7466 aN 31 0 A 3.00
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