HomeMy Public PortalAbout6130 ROWLAND AVE_Sewer__ 76A 642D-CE808 A-7176 APPLICATION FOR PERMIT
SEWER—SEWAGE DISPOSAL u
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
DISTRICT NO. GROUP MAP p CESSED BY
BILDING
FOR APPLICANTTO FILL IN SK PS
U
ADDRESS 0
CONNECTION DATA
LOCALITY /
NEAREST - STATION _ DEPTH
CROSS ST. • s
OWNER
MANHOLE REFERENCE /
(r� y LOWER
E.,.}_ —
TYPE OF CONNECTION LENGTH FROM
MAILY. CURB P.L.' M.L.TO P.L.
ADDRESS r�
-- P.C.NO. "7
•TEL NO. CO. IMP.NO. JOB NO. fl
CITY
LEGAL TRUNK PERMIT NO, ROAD PERMIT NO.
DE_S_CRI_PTION LOT NO.
BLOCK TRACT
AFFIDAVIT WAIVE[ [�s[MENT RECORD.INSTR.NO. I. DATE
NO. OF BLDG$LDG$..
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
STATE ENCROACHMENT
BUILDINGS
PERMIT NO.
INDUSTRIAL r
CONTRACTOR WASTE APPROVAL a
ADDRESS CHARGES 0
CONNECTION CHARGE FEE 0
CITY TEL. NO. lx
STATELIC REIMBURSEMENT FEE 0
I ICENS"t NO., 210 C CLASS
ND. DESCRIPTION O WORK FEE APPROVALS DATE INSPECTOR'SSIGNATU E W
HOUSE SEWER CONNECTING TO - d
PUBLIC SEWER NEW HOUSE SEWER U)
SEPTIC DANK.SEEPAGE PIT OR Z
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 DRAIN FIELD T1
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL ❑ DRYWELL ❑
EXTN..CESSPOOL,DRYWELL.MANHOLE @ —
ALTER.REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S) ❑ CESSPOOLS ❑
OWNER"S Issuance Fee s
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AiTPHORIZATION 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 IBED EXISTING DWELLING i HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
TO THE PUBLIC SEWIEV LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF
SIGNED THIS DA O 19 CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO
OWNER OR RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY,
OWNERS AGENT SIGNATURE
OF PERMITTEE ds
VALIDATIO
CK, M.O. CASH