HomeMy Public PortalAbout6119 ROWLAND AVE_Sewer__ 76A 642D-CE808 A-7/76 APPLICATION FOR PERMIT _
SEWER—SEWAGE DISPOSAL U
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP BK ^ PS AAP ROLE SSED BY
BUILDINGQ
ADDRESS
,.� CONNECTION DATA
LOCALITY
NEAREST STATION DEPTH
CROSS ST. y (�
UPPER
MANHOLE REFERENCE
OWN K
TYPE OF CONNECTIO > LENGTH FROM
MAIL Y. CURB P,L. M.L.TO P.L.
ADDRESS f
P.G.NO.
CO.IMP.NO. JOB NO.
CITY TEL. NO.
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO. _
� !1 � 1 AFFIDAVITt
wMYER 14110INT RECORD.INSTR.NO. I DATE
BLOCK TRACT '
NO. O BLDGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OFSTATE ENCROACHMENT
BUILDINGS PERMIT NO.
INDUSTRIAL
CONTRACTOR WASTE APPROVAL
ADDRESSCHARGES V
CONNECTION CHARGE FEE
CITY TEL. NO.
STATE .°r ;� I L LIC REIMBURSEMENT FEE 0
LICENSE NO.f�(f ✓ CLASS U
NO. I DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATU W
HOUSE SEWER CONNECTING TOCL
PUBLIC SEWER NEW HOUSE SEWER
SEPTIC fANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL s
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM SEPTIC TANK,SEEP,PIT(S)
CONNECT ADDITIONAL BLDG.OR AND/OR DRAINFIELD
WORK TO HOUSE SEWER -----
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL Cl DPYWELL ❑
EXTN.,CESSPOOL.DRYWELL.MANNOLE ALTER,REPAIR,SEWER OR �-
ALTER.REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM j
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S) ❑ CESSPOOLS ❑
OWNER'S Issuance Fee s —
�1 I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AUTHORIZATION TOTAL FEE /f 0(1 AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTYORDINANCES AND STATE LAWS REGULATING
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. PLUMBING AND SEWERS.
TRACTOR TO CONNECT THE ABOVE DE ED EXISTING DWELLING I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
TO THE PUBLIC SE / LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF
SIGNED THIS DA' OF 19 CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF. AND INTEND TO
OWNER OR /J)-/ RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PF PERTY,
OWNERS AGENT - �� �4
SIGNATURE
OF PERMITTEE
VALIDATIO
Cc . IA.0. CASH