HomeMy Public PortalAbout6324 SALTER AVE_Sewer__ D
a&E-689 1.1•$S APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE,COUNTY ENGINEER ADDRESS
CASSATT D.GRIFFIN, SUPT OF BUILDINGLOCA
LITY -
�
FOR APPLICANT TO FILL IN _CRNEAREST OSS ST, ;'' _ y
LEGAL
DESCRIPTION L00TNN"day "'�y�' '•' -+`` OWNER
BLOCK r'L� -AMAIL
DDRESS
- C ✓y =a j ----- - ----- -----
^^ NO OF BLDGS, p -
SIZE OF LOT a� `fi > 'a NOW ON LOT a CITY TEL,N0.
USE OF
BUILDINGS 42- f -' ,�.✓ �.�" `� DISTRICT NO. GROUP MAP
y ✓'
BK PG
CONTRACTOR 4�-
ADDR�Sy',' _ CONNECTION DATA
DEPTH s
STATION r
CITY 4, No
MANHOLE
. .!i,fi •-�:.'� MANHOLE REFERENCE ----:Ift °.'ER-,..:
= NATE
REGISTRATION N0. -''r L-1 COUNTY
NO. DESCRIPTION OF WORK _ FEE -- - - -- ----- ----_---___---
HOUSE SEWER CONNECTING TO - -TYPE OF C-A7 ,CTION LENGTH FROM
y"a i PUBLIC SEWtR C$_3.50 _��y L Y-- �..�•LRBT P.L . M,L_r0 P.L.
i SEPTIC TANK,SEEPAGE PIT OR 0 i
PITS ANDiOR_DRAINFIE_D fa $3.OG - —
OVERFLOW SEEPAGE PIT DRAINFIELD - _ P. C. NO.
-I EXTN.,CESSPOOL,DRYWELL,MANHOLE (n) $2.0.0I _;�O• IMP. NO. y ,,.'"- JOB NO. —
HOUSES EWE R CONNECTING TO -(-' -7-
PRIVATE DISPOSAL SYSTEM (") $1.00 I I _RUNK PERMIT NO. ROAD.PERMIT NO.r
I
CONNECT ADDITIONAL BLDG,OR - STATE ENCROACHMENT
WORK TO HOUSE SEWER is $1:00 j� _ PERMIT N0.
ALTEFEPA[R OR AB 1PlU0N HOUSE - --- ------ --------- -
INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ct $1.00 WASTE APPROVAL
_-'-- --i - CHARGES
-__ CONNEC.TION.CHARGE FEE
'W
ONER'S PERMIT -------- --
----- -- --_
$ fI - REIMBURSEMENT-FEE
AUTHORIZATION TOTAL FEE I �- r "=
I
HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS I DATE -j—
I.iNSPECTOR'SSIG.NA7URE
---------_------ ---'-i- -----
RA.C7O TC CONNECT THE AROVE DESCP BED EXISTING D'v`JELLING
1 --- ---- ------
TO THE PUBLIC SEWER., � f.9. NEW' HOUSE SEWER !, i
SIGNED THIS CONNECT ADDITIONAL ---
OWNER OR 6' "' -� BUILDING OR WORK
OY:NERS ADEN '- . -- -
�- - - SEPTIC TANK,STPD,PITkB)
ADDRESSAND/OR DR AJNFIEtb �...__.--_-------
I HEREBY ACKNCWLEILCE THAI' I HAVE. READ TH15. APPLICATION CESSPOOL{� DRYW ELL,] I �
.AND STATE THAT THE ABOVE 1S CORRECT AND. AGREE TO COMPLY'
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALT-R. REPAIR SEWER OR
PLUM&INv. AND SEWEP.S, .
SEWAGE DISPOSAL SYSTEM
it
_- .NNEC"C EC AND - ---------- ...__..
I x:RE3','' CERTIFY THAT 1 ANIPF,OPERLY REGISTERED .AND/CR D15CON- PLUGAND I
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSESEWER �
C`.i l�'ORNIA GR THAT 1 f THE LEGAL ��'&'NER OF THE ABOVE ---_ -_. .----- --- - ---- ---- --
D':SCRiEEDRESIDEN:T!, PR PER IY, �•" ,•r BACKFILL EPIC,TANKS ] 11
SIGNATURE _ SEEP PST(S). CESSPOOLS
OF PERMI-T'TEE� �/f�M. -
i
JOHN A, LAMBIE, COUNTY ENGINEER VALIDATIONROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. M.G. CASH`.':