HomeMy Public PortalAbout5415 SANTA ANITA AVE_Sewer__ .EB08IREV6,78' APPLI I O E RM IT�
�5
SEWE - S WAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP MAP SSED BY
BK PG
BUILDING
ADDRESS ;��.... �+""'_.J£i i •fr p.,� .d' /(• O l
-x � CONNECTION VAIA
LOCALITY
NEAREST STATION DEPTH
CROSS ST. al
UPPER
�•--� �Lppp MANHOLE REFERENCE
,,f'nu `L { ;y1 Ea.C LOWER
OWNER
_. TYPE OF CONNECTIONLENGTH FROM
MAIL -` CURB P.L. M.L.TO P.L.
ADDRESS ��.,,. -i.=- , L- �,I ..
P.C.
CO.IMP.NO. JOL�.N
CI7V - C- TEL.NO. � 4s
LEGAL • Sy. r_.d F TRUNK PERMIT NO. R A RMIT NOM
DESCRIPTION LOT NO ;±4, d�-- ✓
n _ AFFIDAVIT *AIVER EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT ;i°.-'��_' 0 f
NO.OF BLDG S. -
SIZE OF LOT .; m NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS - k. STATE ENCROACHMENT
PERMIT NO.
CONTRACTOR �.. } !-" _. INDUSTRIAL
WASTE APPROVAL
ADDRESS CHARGES
CITY TEL.NO. ° �' CONNECTION CHARGE FEE
STATE �-•. LIC. f REIMBURSEMENT FEE
LICENSE NO. , -. CLASS '
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE V
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Vv:,h _
S-EPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER - .,..� k; 0
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG.OR SEPTIC TANK,SEEP,PIT(S) Z
WORK TO HOUSE SEWER AND/OR DRAINFIELD _
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL El DRYWELL
EXTN.,CESSPOOL,DRYWELL.MANHOLE
ALTER.REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑
OWNER'S
Permit $ � SEEP,PIT(S)❑ CESSPOOLS
77
AUTHORIZATION I TOTAL FEE ALIDATION
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS�DAY OF
OWNER OR ,/ •r
OWNERS AGENT
ADDRESS ✓� � '`
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTE ED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES CONY AI.D STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF ND t TEND TO RE-
SIDE IN,THE ABOVE DESCRIBED RESIDENTIAL P PE
SIGNATURE
OF PERMITTEE _ • ` P ✓