HomeMy Public PortalAbout6106 SAINT JAMES DR_Sewer_8/31/1983_ cEBoa 1043 APPLICAT ON FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
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FOA APPLICANT TO FILL IN cflasB a
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OtaCRIPTION LOT ND OWNER
MAIL
BLOCK TRACT I ADORE I/
NO OF BLDOB
SIZE OF LOT NOW ON LOT CITT / TEL NO
BU61O NOB DISTRICT NO O OUR _ZAP ✓j P [BBQO BY
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CONTRACTOR 1�o r z
ADDR CONNECTION DATA
CITY TEL FOX Q DEPTH
I
STAT[ UPPER
REGISTRATION NO COUNTY MANHOL[R[P[RENCE rW�
N DESCRIPTION OF WORK PC[ TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO T CURB ML TOP L Y
PUSLIC SEWER
SEPTIC TANK Q[[PAOE PIT OR P C XO O
PITS AND/OR DPA INFIELD SIG GO CO IMP NO JOB NO v
HOUSE SEWER CONNECTING TO TRUNK PERMIT HO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM S) 53 00
CONNECT ADDITIONAL BLD. OR AFFIDAVIT {11Y[E [EE1t11IT RECORD IHSTR NO DAT[ O
WORK TO HOUSE SEWER C ES 00 ty'
OVERFLOW SEEPAGE PIT GRAINFIELD
C[TH CESSPOOL DRYWELL MANHOLE C ES OO d
ALTERREPAIR OR ABANDON HOUSE HWY OR ST WIDENING Z
SEWER OR DISPOSAL SYSTEM 0 [900 STATE ENCROACHMENT
PERMIT NO
INOUtTRIAL
WASTE APPROVAL
CHARGES
OWNER$ PEHMIT s z 00
A=OAIZATION TOTAL FEE 2 ow CONNECTION CHARGE FEE
I HAV[ AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ASOV[ DESCRIBED FwNGI�PPROV}� p (.
TO THE PUBLIC SEWER AALS DATE IHSP R IONATUR[
SIGNED THIS 18_
OWNER OR NEW HOUSE SEWER -I Z-
OW NERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
B�TIC1 HKR[BY ACKNOWLEDGE THAT I HAVE READ THF{ APPLICATION AND/OR
TANK SEEP PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFlQLD
WITH ALL COUNTYORDINANCES AND STATE LAWS REGULATING
PLUM a(NO AND B[WERE CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT 1 AM PROPERLY 0k
ND/OR ALTER REPAIR SEWER OR
LICENSED AS RtOUIR! Y LOS ANGLES NTTE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA Ofl TH TH¢ LIOAL O OPND TO DIKOXNECT PLUG ANO
R[SIDQINTHE DESCRIBED R[B IAL ABANDON HOUSE SEWER
SIONATLR[ / L SEPTIC TANKS ❑
OF PERMITTEE
SE[F PI CESSPOOLS
\ \/ALIDj{TI ROBERT A WOOD
CK M o CASK SUPERVISING MECHANICAL ENGINEER
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