HomeMy Public PortalAbout5417 SANTA ANITA AVE_Sewer__ 330
E 8081REV.6/78! AP I TION i
F ° PERM �
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP MAP JgSBEDBK PGBUILDING
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ADDRESS C4:'� ..
CONNECTION DATA
LOCALITY _
NEAREST -Y v STATION DEPTH
CROSS ST.
._ -_ -- ��_ UPPER
_ r MANHOLE REFERENCE LOWER
v
OWNER '" ar - -:� ,1"I
TYPE OF CONNECTION LENGTH FROM
MAIL �;, Y. CURB P.L. M.L.TO P.
ADDRESS ,8'"-t,
CITY TEL.NO.
CO.IMP.NO. !OB NO.
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LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO. - _ P��`-
_ AFFIDAVIT I WANER I EASEMENT RECORD.INSTR.N3T DATE
BLOCK TRACT
i J NO.OF BLDGS.
SIZE OF LOT}~ - NOW ON LOT HWY.OR ST.WIDENING
USEOF
BOLD NGS " ` �'"" �'� a A' STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
CONTRACTOR
i + r X " � WASTE APPROVAL
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ADDRESS �;' +_-- ��'�&;.+� P a� �I�, CHARGES
TEL NO CONNECTION CHARGE FEE
CITY
of
STATE ` LIC. ry<, REIMBURSEMENT FEE d
All
LICENSE NO. a r CLASS
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE (�
' HOUSESEWERCONNECTINGTO
PUBLIC SEWER NEW HOUSE SEWER 4• '
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK fy4i
PRIVATE DISPOSAL SYSTEM
SEPTIC TANK,SEEP,PIT(S)
CONNECT ADDITIONAL BLDG.OR
AND/OR DRAINFIELD
WORK TO HOUSE SEWER z
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL ❑ 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❑
Permit $ /,r SEEP.PIT(S)❑ CESSPOOLS Ell I
OWNER'S VALIDATION`
AUTHORIZATION TOTALFEE
VALIDATION
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNEDTHIS^, ?'j}A..YOF�} r �"� 1%,_.4
OWNER OR0+. .� ���yyy
OWNERS AGENT
ADDRESS •'--'`
1HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUPITY AND STATE OF
CALIFORNIA OR THAT 1 AM THE LEGAL OW ER OF„AND INTEND TO RE-
SIDE IN,THE ABOVE DE5CR;BE D.REStPEN IAL PROPERTY.
z' F
SIGNATURE
OF PERMITTEE