HomeMy Public PortalAbout5215 SANTA ANITA AVE_Sewer__ E
s&E-663 3•�D APPLICATION FOR PERMIT
i& 6G
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
WM.J. FOX.COUNTY ENGINEER ADDRESS
CASSATT D.GRIFFIN,SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL INNEAREST ��`�
CROSS ST.
LEGAL -
DESCRIPTION LOT N0, .,✓ OWNER -
BLOCK TRACT /,7 MAIL
_
NO. OF BLDGS.
_SIZE OF
—LOT -- NOW ON LOT CITY TEL. NO.
USE OF
BUILD_NGS _, _ _ DISTRICT NO. GROUP ` ASAP
BK PG
CONTRACTOR,
ADDRESS CONNECTION DATA
CITY TEL, N0. _ _--- STATION _DEPTH
D STATE MANHOLE REFERENCE y5 __UPPER_
REGISTRATION NO. COUNTY
N0. ! DESCRIPTION OF WORK--- FEE � --- - --
--.� HOUSE SEWER CONNECTING TO '- ' TYPE OF CONNECTION LENGTH FROM ,fir
LIC SEWER (L Y• CUPS
PUBP_LeM.L. „ :�✓
_ _ _ 5 3_50MTO P
_ �-- — -
HOUSE SEVIER CONNECTING TO
PRIVATE_DiS.P_O_S_AL SYSTEM_ 1.00 ----
CONNECT ADDITIONAL BLDG. OR P. C. N0,
_ WORK TO HOUSE SEWER 1.00 Co. IMP_ NO_ ,:OB NO.
`I ALTER OR RERAIR EatSTI%_
SEWER OR DISPOSAL SYSTEM 1,00 TRUNK PERMIT N0. . ROAD PERMIT NO,
CIS _ CT ANDABANDON_ _SEWER
AND/0R, 1) SPCSAi SYSTEM . STATE ENCROACHMENT
--- - _P ER hI 1 T r O.
SEr'7!C TAtd K,SEEPAGE PIT OR �� INDUSTRIAL
�—
Pi7S_AND/OR DRAINFIELD 2.00 ,J INDUSWAS E RIAAPPL AL.
CESSPOOL DRYWELL
SPtCIAL CONDITIONS ONLY _ 2.00 CHARGES
-�..� �_,
CONNECTION�CHARGE FEE
OWNER'S PERMIT i 00
AUTI"IORIZATION I TOTAL HE —`� ,y REIMBURSEMENT FEEFE
1 HAVE THIS DATE CONTRACTED WITH "HE HEREIN LAMED CON- py �p��e
"IRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE �INSPECTOR'SSiGNA7'URE
TO THE PUBLIC SEWER ----- ----- --.4—_—..----,_.---- ------
NEW HOUSE SEWER
SIGNEDTHiS --DAY OF ��_�i9__ ______ _
OWNER OR ---
CONNECT ADDITIONAL
BUILDING OR WORK
O'v5'PfEP.S AGENT __-_ _ —
_`— —�---------------_--�-- SEPTIC TANK, ''EEL, PIT(S)
ADDRESS_._. AND/OR DRA1'?_F_IELD — _ ---_
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL 0 DRYWELL 0
A1,, STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR SI;W6R OR
PLUMING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AMPROPERLY REGISTERED AND;GR '— - — - —"-' ”--'�-�
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAI I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE.SEWER.
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SEEP._
SIGNATURE
PIT(5) ❑ CESSPOOLS C3
1
OF PERMITTEE
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION R.A.WOOD.CHIEF PLBG. INSPECTOR