HomeMy Public PortalAbout5419 SANTA ANITA AVE_Sewer__ ------
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CE 808 iREV.6178'
�V5 APP I O N FP E R
S W - SEWAG DISPOSA
COUNTY OF LOS ANGELES BUILDING AND SAFETYZG
DISTRICT NO. GROUP MAP PRO ESSED BY
FOR APPLICANT TO FILL IN
y ex PG
BUILDING - � h JfA
ADDRESS
CONNECTION DAT, ✓
LOCALITY '
NEAREST !"• STATION DEPTH
CROSS ST. r �`
UPPER
MANHOLE REFERENCE LOWER
OWNER `4 l r�y., .t
- ^� TYPE OF CONNECTION LENGTH FROM
ADORESS,MAIL `� Y. CURB P.L. L •L• r{_„
CO.IMP.NO. JOB NO. C(�
CITY _ TEL NO.
LEGAL ` TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO. .. ,. ---- ,.rc«'
AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO, DATE
BLOCK TRACT -
t NO.OF BLDGS.
S12E OF LOT ,<.'_Y,.NOW ON LOT "�'�''� HWY,OR ST.WIDENING
USE OF C
BUILDINGS - '�_ �/ '� -p,�L,'..'7G.-� STATE ENCROACHMENT
PERMIT NO.
CONTRACTOR �' S • INDUSTRIAL
f." " ��I^•� WASTE APPROVAL
ADDRESS' � CHARGES
CONNECTION CHARGE FEE
CITY `�.-�- TEL.NO.
STATE .r - LIC. - REIMBURSEMENT FEE
LICENSE NO. „ � L:_.- "" CLASS '-
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE u
/ HOUSE SEWER CONNECTING TO / rq .R 09
PUBLIC SEWER /
SEPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER
PITS
AND/OR DRAINFIELD CONNECT ADDITIONAL y
HOUSE SEWER CONNECTING TO BUILDING OR WORK IyLi
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG.OR SEPTIC TANK,SEEP,PIT(S)AND/OR DRAINFIELD
WORK TO HOUSE SEWER z
OVERFLOW SEEPAGE PIT,DRAINFIELO CESSPOOL L✓ DRYWELL❑
EXTN.,CESSPOOL,DRYWELL,MANHOLE
ALTER,RE PAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
$ BACKFILL SEPTIC TANKS Ej
Permit �J SEEP,PITISI❑ CESSPOOLS:1OWNER'S C , --VALIDATION
AUTHORIZATION I TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. - +
SIGNEDTHIS DAYOF ..<..rr�, 1J.,
OWNER OR
OWNERS AGENTO^"•
ADDRESS
I HEREBY 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.
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY APD STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER,AND TEND TO RE-
SIDE IN,THE ABOVE DESCRIBED RESIDENTIAL ROPERTY.
SIGNATURE _ Jam.".✓'"~
OF PERMITTEE
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