HomeMy Public PortalAbout6125 ROWLAND AVE_Sewer__ 76A 642D-CE868 A-7/76 APPLICATION FOR PERMIT ,
SEWER—SEWAGE DISPOSAL.
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLIC T TO FILL IN olsTRlcT No. GROUPI SK MAP PS OCESSED 8V
BUILDING
A.
LOCALITY
CONNECTION DATA
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NEAREST STATION c, � DEPTH
CROSS ST. �
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MANHOLE REFERENCE yj % i/ LOWER
OWN _ TYPE OF CONNECTi-07"• (p J LENGTH FROM
MAIL n. Y. CURB M.L.TO P.L. 3L
ADDRESS a 1 '
P.G.NO.
CIT •TEL. NO. CO. IMP.NO. JOB NO. `
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO. _
�3 �3�V -- AFFIDAVIT wArvu I [ASCM[tli RECORD.INSTR.NO. I DATE
BLOCK TRACT
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF STATE ENCROACHMENT
BUILDINGS _ PERMIT NO.
INDUSTRIAL
CONTRALTOWASTE APPROVAL CL
ADDRESS d� ""w�+C CHARGES 0
CONNECTION CHARGE FEE
CITY . TEL. NO. _ O:
STATE LIC REIMBURSEMENT FEE 0
LICENSL NO: 1 �, .r- CLA 55 V
No. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE LLJ
0
HOUSE SEWER CONNECTING TO j - (L
PUBLIC SEWER / r Z
SEPTIC TAK.SEEPAGE PIT OR
NNEW HOUSE SEWER -
PITS AND/OR DRAINFIELD @ CONNECT ADDITIONAL
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 ❑ DR-YWELL ❑ i
EXTIN CESSPOOL,DRYWE LL.MANHOLE @ --- - -
ALTER,REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR j
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑
SEEP,PIT(S) El CESSPOOLS ❑
OWNER'S I Issuance Fee s
1HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION
AUTHORIZATION TOTAL FEE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- PLUMBING AND SEWERS.
TRACTOR TO CONNECT THE ABOVE DES ED EXISTING DWELLING I HEREBY CERTIFY THAT AM PROPERLY REGISTERED AND/OR
TO THE PUBLIC SEW R, ,I LICE
NSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF
SIGNED THIS DAY O 19 CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO
OWNER OR �.y RESIDE IN, THE ABOVE �ESCRIBED RESIDENTIAL PROPERTY.
OWNERS AGE T "�'l� �/
SIGNATURE ,y /
OF PERMITTEE /1,
VALIDATION
CK'• I,A,U. CASH