HomeMy Public PortalAbout5571 RYLAND AVE_Sewer__ :E®0�r°A e42 10 - APPLICATION FOR PERMIT `
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AI40 SAFETY DIVISION BUILDING '5-
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS 3 7
COLEMAN W. JENKINS. SUPT. OF BUILDING r7
LOCALITY
NEAREST 171
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL 'f
DEfiCRIPTION LOT NO. . OWNER �c�ad
s MAIL
BLOCK TRACT L ADDR€SS - � ! '
6. OF SLOGS,
SIZE OF LOT NOW ON LOT CITY C TEL. NO.
USE OF DISTRICT NO. ROU MAP PROCESSED BY
BUILDINGS
SK
CONTRACTOR -y /I�i f�"f �L��Y�i/ J f (�>
ADDRESS. !`,7"% /'�fr .{� CONNECTION DATA
CITY -`,' ✓.a ��.��'�'�r�'TEL. NO. � �FY STATION DEPTH
STATE r LICMANHE REFERENCE - UPPER
LICENSE NO, CLASS •°o LOWER
NO, DESCRIPTION OF WORK FEE TYPE OF'SQNNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. ClTRB., P.L. M.L.TO P.L.
PUBLIC SEWER $5.00 —'—
SEPTIC TANK.''SEEPAGE PIT OR "`, P.C,NO.
MPNO. a'"^•-.mJOB NO.
PITS AND/OR ORA9Nr(ELD @ SIO:00 Co.. . _. -__
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PER
PRIVATE DISPOSAL SYSTEM $3.00 l "•a,a
� CONN EC7 ADDITIONAL.BIEiiiEPf� i E AFFIDAVIT WAIVER CASEMENT RECORD. INSTR.NO.
WORK TO HOUSE SEWER @ $3.00
�OV£RFLOW SEEPAGE PIT,GRAINFIELD i _ �� ----
EXTN.,CESSPOOL.DRYWELL.MANHOLE 0 $5.00 HW V.OR ST.WIDENING
ALTER:REPAIR OR ABANDON HOUSE —�� W
SEWER 0R DISPOS.AL SYSTEM $3.00 ATE E -'---E
___- ..__...__-._ _� �_--.. STATE ENCROACHMENT yr % _. _
iPERMIT NO
-'-P ---- INDUSTRIAL
I WASTE APPROVAL_- _ h .._
CHARGE
OWNER'S i00CONNECTION CHARGE FEE
AUTHORIZATION[PERMIT
TOTAL FEE --.-
I HAVE AT THIS DATE ACONTRACT WITH THE HEREIN NAMED CON, REIMBURSEMENT FEE
TRACTOR TO,CONNECT THE ABOVE DESCRIBED EXISTING DWELLING --- -------
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19T ---"--�-- -- --
OWNER OR NEW HOUSE SEWER g
OWNERS AGENT_ CONNECT ADDITIONAL )
— BUILDING OR WORK
ADDRESS_". –
SEPTIC TANK,SEEP,PITS) - 1
IHEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND `STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYWELL ❑
i HEREBY CERTIFY THAI' I AM PROPERLY REGISTERED AND/OR ALTERO
.,REPAIR.SEWER R `
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM I
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO —
RESIDE IN, THE ABOVE SCRIBED RESIDENTIAL PROPERTY. DISCONNECT PLUG AND t
ABANDON HOUSE SEWER
SIGNATURE ----"----� —'-- ---
OF PER MiT7EE_ BACKFILL SEPTIC TANKS ❑ + i"
-- SEEP.PIT IS
❑ CESSPOOLS
VALIDATION JACK R. ALLEN
CASH SUPERVISING MECHANICAL ENGINEER-