HomeMy Public PortalAbout5950 ROWLAND AVE_Sewer__ :sa�a64 A6A6420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SWAGE OISPdALa
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
TA
JOHN A. LAMBIE, County EngineerDR ssWILLIAM A. JENSEN. Supt of Building
:AL.'TY
R.E T F'OR APPLICANTTO FILL IN55 5T
LEGAL ' _•�-
DESCRfPT-ON LOT NO. OWN=.F
BLOCK -(AGl $ � �__ ADORES
NO. OF F' D'S.
SIZE O} 4.0T
NOW ON LOT CITY TEL. No.
t3 - �Y +
LSF OF j `'
.._.._ -� - ti BCD
DISTRICT NO. GROUP NAP PROCESSED BY
LD
Bl'! ihG'
SK rG
CONTRACTOR
UCRF - j CONNECTION DATA
IT), t'JEL. NO. STATION _ _ DEPTH ..
STAT'Eg
REGISTRATION NO. COUNTY MANHOLE.REFERENCE
: LBwY;r F2
N0, t'BSCRi PTiON OF WORK rE:F __ TIP OF CONNECTION LENGTH FROM
T_HOt3 rY 5EW R GO NN EGTIC'dG T'O. CURB F.L. M.L TO P.L.
V'c
j PUBLIC SE R ` $F5
.a0 T .C.NO _-.—
F'
ERY ( TAN SE=PAGE PIT OR JOB[v0
P!7>ANDI OR O'a AINFIELD $10.00 CO IMP t0_ -- _-.� _ _- -._-- ._ --� -__-
..__ --.. ___ o.-__.
HOUS_5EW 1.,CCNYiE'71NG TO TRUNK PERMIT N0. /. ROAD PERMIT NO.
PRIVATE DISPOSAL SYS,EM @ $3.00
c.Oh Nt-CT AD D'T!0NA BLDG OR AFFIDAVIT 1 a'BfYt4 I tas EM KBIT 7' RECC'RD.INS1 r' h DATE '-
V.ORK T..^.HO F.SEWER C $3.00 �..
OVc FL.O J. _YLPAGE I..ORAINFIELO A J--_._�-.__---_s _-_—_ - _�_J --__-_...— o-
EXT 7.,CC[SSI O L,D YWELL.MANHOLE @ $5.00 II
_._ _. —_ '3
m-mti:4SA^:DO !HOUSE
HWY.OR SY,WIDENING
"
F 'ER n .. ..
_. P _....-_ STATE ENCROACHMENT -
PERMIT NO.
iN.DU.STRIAL
j WASTE APPROVAL ..
CHAR
._.-.-_.__-.-__ GES
OVVNEFi`S &�ERIvIIT $II z no _ ----
___...__ .__- CONNECTION CHARGE FEE
__TOT --��
AUTHORIZATION AL FEES
'iHAVE AT THIS DATr... A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
T'AACTOR TO co N .r,T THF ABOVE DESCRIBED EXISTING D%'F_LLING _._._. __-
TO THE PUBO _..C SEWER. APPROVALS 1 DATE �INSPECTORS SIGNATURE
SIONf_C3 THIS DAY
OWNER CR NEW HOU`E SEWER
OW N E R S A G E;NT_ _ _ __ ---- CONNECT ADDITION AL Y`
aUi L.DiNG OR WORK i
AOCIRESS
F'PYi4W TANK,56. r.P:T(`:)
IIF kEB'( ACKNQVVi El-(-,FTHAI' . HAVE READ TN 5 APPLICATION AND/OR URAi N!-11:LD
AND STATE THA71 TPP ABOV€ S CORRECT AND AGREE TO COMPLY .--.---. ---------=------ ------ -------
WITH ALL COUNTY cOROINAN,1'FS .AND STATE LAWS REGULATING � I
PL j a IN'G AND SEWERS. CE'SSPO"L El DRYWELI_
HEREBY CERTIFY ';'HAT AM PROPERLY REGISTFRED AND/OR ALTER,REPAIR SEWER OR T
l i
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE.DSPOSAL SYSTEM 'I J
CALIFORNIA O A' I AM THE LEGAL OW 0F, AND INTEND TO --_— _._._
5 IS:.ONNE&,7 UG AND
I -
RESIDE. IN, 'PH C DF:sc ED RE97 J I' L P SPE.TY. ABANDON HOUS SEWER
SIGNATURE
OF PERE y BACKFfLL SEPTI('TANKS
._ ._ .. _ _ _.:_— SEEP.PIT{S) ❑ CESSPOOLS
VALIDATION. ROBERT A. WOOD
____,... SUPERVISING MECHANICAL ENGINEER
CK. W 0, (ASH z