HomeMy Public PortalAbout6040 ROWLAND AVE_Sewer__ A- 71 ......
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CE808 2/70
76,A 642D APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-§VAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
I-
ADDRESS
JOHN A. LAMBIE. COUNTY ENGINEER D
COLEMAN W. JENKINS. SUPT. OF BUILDING
LOCALITY
BUILDING
_ S
FOR APPLICANT TO FILL IN CROSS ST.
(PRINT OR T- E ONLY)
_DESCRIPTION OT NO 7 OWNER
MAIL
BLOCK TRACT t4, q,
ADDRESS
NOOF BLOGS
SIZE OF LOT NOW ON LOT CITY C, r4noo.
USE
BUILDINGS DISTRICT NO.1 GROUP]CLASS "A'P R ESSE Wel
F3 K P3 / "'
:Izo
CONTRACTOR c; I —
ADDRESS CONNECTION DATA
7 ?'Q STATION DEPTH
CITY TEL. NO.
STATE LICUPPER
MANHOLE REFERENCE A ti.
LICENSE NO, CLASS
TYPE OF C LENGTH FROM
No. DESCRIPTION OF WOlil< FES TIO-N
+4liu-s�l:--SEW ER CONNECTING TO Y. M,L To P.L.
PL BA IC n r7i,
SEWER @ $5.00
P.C.NO.
SCP IC rANK,SEEPAGE PIT OR CO. IMP. NO. JOB NO.
PITS ANO/QR ORAINFIELD @ SIOO
[--TSIO.
OD
SFWERCONNECTING-TO
PRIVATE DISPOSAL SYSTEM @ $3.00 TRUNK PERMIT NO. ROAD PERMIT NO.W131
CON NEC:7 ADDITIONAL BLDG.OR � -A-FFADA-vrrl AiVER I cAsvmcNT RECORD.INSTR.NO. DAYS 0
WORK TO HOUSE SEWER $3.00-
_EXTN-CESSPOOL.DRY WELL,MANH.OLE $5,00
ALiE-R-RlEP-.ATR6R HWY. OR sr.WIDENING
------SEWER OR DISPOSAL SYSTEM ------ -i `STATE ENC R OAC H-ME N T
PERMIT NO, IDS..
INDUSTRIAL (n
WASTtPPROVAL z
CHARGES
OWNERS MIT
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE moo
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPEC OWSSIGNATURE
SIGNED THIS DAY OF-- —19—
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PJT(S)
I HEREBY ACKNOWLEDGE THAT I 14AVE READ THIS APPLICATION AND/OR DRAINFIFLD
AND STATE THAT THE ABOVE is CORRECT AND AGREE TO COMPLY
WITH ALL. COUNTY
ORD{NANCES AND STATE LAWS REGULATING
FLU ME ING AND SEWERS CESSPOOL ❑ DRYWEL.L
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR Al:�IER.REPAIR,SEWER OR
LICENSED
LIC E NSED RED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
C 1 1'AS UiRED
ADDRESS._..____
HEREBY
E RE'
AND
0 5 T AT E
�T- A L L
FLU
M I N A
I HEREBY
I-E N�;E. a'
I A
AL FOWN A OR THAT I AM THE nAL OWNER OF AND INTEND TO
E DISCONNECT PLUG AND
RESIDE IN, THE AS�XEIDESCRIiir DjRES�p NTIAL PROPERTY. ABANDON HOUSE SEWER
RESIDE
SIGNATURE BACKFILL SEPTIC TANKS
OF I,M 5)
OF PERMrTTEE SEEP.PIT(5)
CESSPOOLS
VALIDAT O � JACK R. ALLEN
UERVISING MECHANICAL ENGINEER
CK.
ASH
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