HomeMy Public PortalAbout4923 RYLAND AVE_Sewer__ i
`E8 vbi78 APPLICATION FOR PERMIT
�5
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTR[CT No. GROUP MAP PRo(,ESSED BY
BK PG
BUILDING -
ADDRESSe"�
CONNECTION DATA
LOCALITY
iNEAREST �,J f �, STATION DEPTH
CROSS ST. ,�. d7 i�fes"" W -E..-l.` ` 6a.Y-4
UPPER
MANHOLE REFERENCE LOWER
OWNER ,/,�/� /
���_a, � ��e°~ TYPE OF CONNECTION LENGTH FROM
MAIL ,e� Y. CURB P.L. M-L.TO P.L.
ADDRESS �'„�. .� fs "!d-.._..9 J/6'' ,
P.C.NO.
CITY 7-d, '0.',r TEL.NO. CO.IMP,NO. JOB NO.
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
CONTRACTOR - WASTE APPROVAL
ADDRESS - CHARGES
CONNECTION CHARGE FEE
CITY TEL.N0--
STATE LIC. REIMBURSEMENT FEE
LICENSE NO. CLASS C
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE V
HOUSE SEWER CONNECTING TO at
PUBLIC SEWER 0
NEW HOUSE SEWER
SEPTIC TANK,SEEPAGE PIT OR y`,
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL `' V
HOUSE SEWER CONNECTING TO BUILDING OR WORK d - �'� !�'+"`•-- iiiYYYY
PRIVATE DISPOSAL SYSTEM d
CONNECT ADDITIONAL SLED-'t"* SEPTIC TANK,SEEP.PIT(S) '
WORK TO HOUSE SEWER _ AND/OR DRAINFIELD _
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL a 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❑
OWNER'S
Permit $ SEEP,PITIS)❑ CESSPOOLS
AUTHORIZATION I TOTAL FEE VALIDATION
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNEDTHIS �.� DAY OF r' f 19�
�S -R
OWNER OR
OWNERS AGENT
ADDRESS��
! HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF.AND INTENDTO RE-
SIDE IN,THE ABOVE DESCRIBED RESIDENTIAL PROPERTY.
SIGNATURE
OFPERMITTEE .✓' ` ^---�'+' "�