HomeMy Public PortalAbout5517 ROBINHOOD AVE_Sewer__ k
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� we4iD APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE C-ISPOSAL
DEPAHTMI�IT OF COUNTY ENGDVI;ER
BU=ING AND SAPETY DIMION ■UILDI NO
JOHN IL TIMRTR. ADDR-
L 0(rA,i STY
NEAREST
FOR APPLICANT TO FM1 IN CRO" ST.
DESLIKOAL "76
CRIPTION LOT NO. OWNER f
MAIL
C
■LOK TRA ADDRR.SY
IND. OF SLDOS. .
SIZE OF LOT NOW ON LOT CITY T.L. Nb
U COL
L
■UIDINOS DISTRICT NO. RP MAP( PROCESSED BY
CONT RA CYOR
ADDRESS 6 �- CONNEC ON DATA
CITY Tl[L. NO.
4 STATION{ DEPYH
RAT[ UPPWR
REGISTRATION Nb. COUNT' MANHOL=REFERENCE L
No. DESCRIPTION OF WORK AIE TYPE OF CONNECTION LENGTH FROM
HODS[SIEWFR CONNECTING TO Y. CURB P.L MSL.TO P.L.
PUBLIC S[W[R • $17.00 P.G.NO.
SEPTIC TAH K,SEEP OE TfT OR .101 Nb,
PITO AHD/OR DRAINFI[LD • $
10.00 GO.IMP. NO.
HDU BE SEWER CONNECTING TO
PRIVATE DISPOSAL SYQTEM • $7.00 TRUNK PERMIT NO. ROAD PQ1MR NO.
CONNECT ADDITIO AL BLDG.opt AFFIDAVIT WUrn wtil[ST RECORD.INMTR.NO. DATE
WORK TO HOUSE SEWER • $3.60
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTH.,CESSRAOL,DRYWFLLMANHOL[• $0.00
A LTI R, - sm 14ouki HWY.OR ST.WID"INq
SEWER OR DIMPOSAL MY TIM • S3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WAPP AL
rjr;
OWNms PERMIT s x 00
A TITIIORMATION TOTAL FEE CONNICTI C}1ARGE
I HAVE AT THIODATE A CONTRACT WITH THE HEREIN NAMED CON, REIMBU RpKMENT FIE
TRACTOR TO CONNECT THE ASOV[ DESCRItKP G(IBTINO DWELLRNO
TO THE PUBLIC SEWER. APPROVALS DATE INSP[C.TOR'S SIGNATOR[
SIGNED THIS DAY OF _ 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADQITIONAL
ADDRESS OUILDI NO OR WORK
SEPTIC TANK,SI'V,PIT(e)
THEREBY ACKNOWL[DOE THAT I HAVE REED 71116 APPLICATION AND/OR DRAT NI`I[L.D
AND OTAT[ THAT THE ABOVE IS CORRECT AND AGREE TO 'COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND R[rVERS, CESSPOOL [IDRYVy[LL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.R"AIH,SEWER OM
LICENSED AS R[OUIR[D BY LOS ANOL" COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
dALIFORNIA OR THAT I AM THE LEGAL OWN R O AND INTEND TO
RESIDE IN, THE ASOV[ DEOCRIBED RAID I I1 DI ONNECT PLUG AND
ABANDON NOUS[SEWER
SIGNATURE
OF PERMTTTA.E OACK FILL•rr�C TANKS ❑
SEEP.Patel LJ cEsaroou
G
VAMATION ROBERT A. WOOD
Y.O. GAlH &UPERVISiNG MECHANICAL ENGINEER
Lj]i� 3308G- APR 15 1 0 D 5.00-