HomeMy Public PortalAbout6126 ROWLAND AVE_Sewer__ 76A 642D-CE808 A-7/76 APPLICATION FOR PERMIT
SEWER—SEWAGE DISPOSAL u
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY-EASIGINEER
BUILDING AND SAFETY DIVISION
FOR_APPLICW TO FILL IN DIS`RICT NO. GROUP BK "AAP PS OCESSED BY
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CITY/*' -TEL, NO, C� —
GAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LCT NO. _
AFFIDAVIT WAIVEe uStM ENT RECORD.INSTR.NO. I DATE
BLOCK TRACT Jy (jam,
NO, OF BLDGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF STATE ENCROACHMENT
BUILDINGS PERMIT NO.
INDUSTRIAL
CONTRACTOR a
WASTE APPROVAL
ADDRESS - CHARGES C
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CONNECTION CHARGE FEE
CITY TEL, NO.
STATE LIC REIMBURSEMENT FEE C
LICENSE NO. CLASS
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'SSIGNATUR W
HOUSE SEWER CONNECTING TO - ' 0.
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PUBLIC SEWER 0 -- NEW HOUSE SEWER Z
SEPTIC TAK.SEEPAGE PIT OR _ -
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 @ Q�=�
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL DRYWELL
E XTN..CESSPOO El L.DRYWELL.MANHOLE ALTER,REPAIR,SEWER OR
ALTER.REPAIR OR ABANDON HOUSE � I
SEWER OR DISPOSAL SYSTEM @ SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S) Cl CESSPOOLS ❑
OWNER'S Issuance Fee
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AUTHORIZATION TOTAL FEE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
I HAVE.AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- PLUMBING AND SEWERS.
TRACTOR TO CONNECT THE ABOVE DES C BED EXISTING DWELLING I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
TO THE PUBLIC SE LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF
SIGNED THIS DAY OF 19 / CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO
Y,E DESCRIBED RE51DE
OWNER OR RESIDE IN, THE ABONTIAL PROPERTY,
OWNERS AGENT ` SIGNATURE
OF PERMITTEE
VAS JDATIO
M.O. CASH
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