HomeMy Public PortalAbout5425 SANTA ANITA AVE_Sewer__ 16A 6420-KEBOB-10-71 APPLICATION FOR PERMIT
• COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING r
ADDRESS
LOCALITY
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
�f'4�Cll S MAIL
`f
BLOCK TRACT ADDRESS
NO. OF BLDG5.
SIZE OF LOT t�'Z S NOW ON LOT CITY TEL. NO.
USE OF / `
BUILDINGS t DISTRICT NO. GROUP BK MAP PR CESSED BY
PG
CONTRACTOR � �. C :�a �^j' �T t hili `•..
ADDRESS ,� CONNECTION✓DATA
STATION DEPTH
CITY I' V
UPPER
STATE /� LIC MANHOLE REFERENCE —
LICENSE NO, ��6" CLASS �'-` L 1 q LOWER
NO, .DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER 0 $7.00
SEPTIC YANK.SEEPAGE PITOR P.C.NO.
PITS AND/OR DRAINFIELD @ ;10.00 CO.IMP,NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO, r CL
PRIVATEDISPOSAL SYSTEM @ $3.00 L O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wAly Fll [1sEMFpr RECORD.INSTR.NO. DATE (�
WORK.TO HOUSE SEWER 53.00
OVERFLOW SEEPAGE PIT.DRAINFIELD DL
EXTN..CESSPOOL.DRYWELL, @ $5.00 O
ALTER,REPAHWY.OR ST.WIDENING
IR OR ABANDON HOUSE - V
SEWER OR DISPOSAL SYSTEM 53.00 STATE ENCROACH MENT W
MANHOLE ! $7.00 PERMIT NO. a,
h
INDUSTRIAL �. Z
WASTE APPROVAL I .
BARGES
OWNERS PERMIT s 3 oa
`�
AUTHORIZATION TOTAL FEE. CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER, APPROVALS DATE INSPEPTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER i, (,: .?(,.,fe•. ''-r'(,:
OWNERS AGENT
CONNECT ADDITIONAL !
ADDRESS BUILDING OR WORK
I
HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE.46ESCRIBEO RE IDF�MTIf'6y,PROPERY.
j AND HOUSE SEWER
SIGNATURE
OF PER MfT7EE_ B C FILL SEPTIC TANKS ❑
SEEP.PIT(S) ❑ CESSPOOLS
VALIDATION CK. M.O. CASH