HomeMy Public PortalAbout5521 RYLAND AVE_Sewer__ LAE CITY
SA8420 APPLICATION FOR PERMIT
eeoe a-ss 4 COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING >
ADDRESS
JOHN A. LAMBIE. County Engineer
CASSATT D. GRIFFIN, Sup t of Building LOCALITY "
NEARS
FOR APPLICANT TO FILL IN cRoss sr. j
LEGAL OWNER / Y/- ^�:/l ' •=' "�
DESCRIPTION LOT NO MAIL
BLOCK TRACT /- -7 ADDRES �Z/ s 144
NT OF BLDGS. t-3
USEOF LOT NOW ON LOT CITY TEL. NO.
USE OFDISTRICT N0. .GROUP MAP PROCESSED BY
BUILDINGS In > .f',t - -'"a - K PG _
CONTRACTOR
ADDRESS CgWNECTION DATA
CITY TEL.NO. STATION DEPTH
❑ UPPER
STATE MANHOLE REFERENCE
REGISTRATION NO. ❑ COUNTY LOWER
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Ca $3.00 TYPE OF CONNEC, ION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB,/ P,L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..Cf:SSP00L,DRYWELL @ $2.00 P.C.NO.
HOUSE SEWER CONNECTING'TO CO.IMP. N0. JOB NO.
PRIVATE OISPOSAL SY57EPA @ $1.00
WORK T TH D ITIS WELBLDG.OR @ $1 00 �ti-(�i TRUNK PERMIT NO, ROAD PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWRR'SPERMIT s 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS AND/OR DRAINFIELD
IH
ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT i AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND ST]]]]ATE OF ABANDON HOUSE SEWER
CALIFORNIA OR Th 1 AM THE LEGAL OWNER OF T ABOVE ❑
DESCRIBED RE�4tSENTI PROPERTY. SEEP.PIT BACKFILL€S)SEPT❑IC CESSTANKS
POOLS
SIGNATURE I
OF PERMITT
)r VALIDATION ROBERT A. WOOD
CR. H.O. J CASH SUPERVISING MECHANICAL,ENGINEER