HomeMy Public PortalAbout5936 ROWLAND AVE_Sewer__ ::ESDB 9G�62
7 6 A S42ll APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEAREST
Yt`oWN A. LAhIBIE, County Engineer WILLiAM A. JENSEN, Sufi'} oI Building + �, f:! 1,1If
y y_FO APPLICANT TO FILL IN _ FF
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4 :iC'IN05 DISTRICT NO. GROUP MAP PROC£$SED B'Y
ADeR.55 ' y CONNECTION DATA
STATION DE—H —
STAT_
MANHOLE RFFERFNCE
REG:' R4Y10\ 'v 0: OUN"f Y`
NO. DFSCRIF IO1i Or WORK FEE �-_—T PEO F Cfj.44E-0T IO.N LEN_..1¢',FROM
}+OU E SEWER�.C3tv'd_CNNG TO Y. CURB P.L, M.L LO P.L. - CJ
P fB ,:,. 1sEL1CR �� 55.00
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s F-TIC TANK,SEAGE PIT OR 1' Lib NO.
PI'SCo.!MP NO AND/OR ORAINI IELD '� Sf O.00 �
pCU G£E WEA'L.UI NE TING TO I TRUNK PERMIT NO, ROAD PERMIT NO.
'@ $3.00
r ON CC AD') IONAL Bt.DG OR A]T:FIDAVIY KAItlE.4 EA.SEKENT I REC O?D.IN`_-iTH NO. .DATE �
.WORK TO IC USE Sf WFR @ $3.00 j I -
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OVERFLOW SEEPAGE PIT,DRAINF ELD
LXTN CESSP 1710 DRYWEI.LMANHOL.E 55.00
ABANDON HDCJS€ ..— _ _—- HW\'.ORS WIDE NCa
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15 df R.C' c ^" '-M STATE EN{.RQAr,}.. �N
PERMIT NO.
INDUSTRIAL
_ - I WASTE APPROVAL
CHARGES
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A ld,L.Y3ORI ATIOD4 TOTAL FEE, –}—�
CONNECTION CHARGE:FETE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON" REIMBJ R5EME:'^1T e_EE
TRAC OR TO CONNECT '?"HE ABOVE OESCRMED EXISTING DWELLING --_.--_ yy_g�_ —@y--y_'_g.+a1
TO THE wU ,t BC SEWER. APPROVALS ALDATE I INSPEC TDR v:,!GI`AA74JR E.
SIGNED THIS ---DAY OF-------. -
OWNFR OF? NEW HOUSE SEWER
OWNERS CONNEr: ADDITIONAL
BUILDING OR WORK I
ADDRESS._.� —.--__, ___
.---. _--_ S: DTIC TANK,SEEP,PIT(S) !
i HERLBy Ar"KNOWLE TGE THAT I HAVE READ THIS APPLICATION .AND/OR DRAIN.FIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITHALLCOUNTY O DU NANCES AND STATE, LAWS REGULA'T'i N.G j
FLUM BiNG AND SERV F.RS. CESSPOOL ❑ DRYWELI-
I HEREBY CERTIFY -IRTHAT 1 AM PROPERLY REG!5TE RED AND/OR ALTER,REPA}R,5E:.4V OR _--
!CEN$EO AS RE iJIREQ BY LOS ANGLES COUNTY AND STATE OF S'E'WAGE.Oi:SPOSAi_SYSTEM
£ALiFORNIA c7R T' _AT M 'CHS '.GAL OWNER ANO TEND 7O
RE$i17E IN, THE DES:RIB RE5IDEN- A F Fi Y. CONNECT PLUG AND
ABANDON HOUSE SEWER ..
SIGNATURE �i_�.�._.__
OF' PERMITTEE I BA KFILL SEPTiC TANKS []
—— SEEP,PITS) ❑ CESSPOOLS f
VALIDATION� =_ ROBERT A. WOOD
SUPERVISING MECHANICAL. ENGINEER
CK. M.O. 1CASH
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