HomeMy Public PortalAbout5826 TREE ROSE TER_Sewer__ CSAOS' °' APPLICATION FOR PERMIT
TpApA1D COUNTY OF LOS ANGELES SEWER—SEWAGFvPlSP0.%AL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
COLEMAN W JENKINS SUPT OR BUILDING
LOCALITY
NEARE{T
FOR APPLICANT TO FILL IN ROSS pT
LEGAL
Dcaewllllon LOT rvo _
MAIL
BLOCK TRACT g ADDRESS
O OF BLDOa
SIZE OF LOT NOW ON LOT CITY TEL NO
use OP DISTRICT NO I GROUPMAF I PROCESSED BY
BUILDINGS
BK PG
CONTRACT
ADGweaa CONNECTION D31LTA
/ STATION DEPTH
CITY MO
pLICCNB[ NO CL pt MANHOLE REFERENCE :1216
NO DESCRIPTION Or WORK FEE TYPE OF CONNECTION NOTH FROM (/ /
HOUSE SEWER CONNECTING TO Y CURS L M L TO P L I,
PUBLIC SEWER O ES p0
SEPTIC TANK SEEPAGE PIT OR PC NO
PITS AND/OR ORAMFIELD 0 EI000 CO IMP NO JOB XO O (J
HOUSE SEWER CDNNECTINO TO TRUNK PERMIT NO ROAD PERMIT NO OC
PRIVATE DISPOSAL SYSTEM d $a GO O
CONNECT ADDITIONAL SLOG OR AFFIDAVIT u. LV11R110IT RECORD INpTR NO OATS L..
WORK TO HOUSE SEWER $3 Go tSj,
OVERFLOW SEEPAGE PIT DRAINPIELD
EXTN CESSPOOL DRYWELL MANHOLE O ES GO d
ALTER REPAIR OR ABANDON HOUSE HWY ORpT WIDENING Z
SEWER OR DISPOSAL SYSTEM 0 Ei OG STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OwNExIs CHARGES
J p1:[{[�QT f 2 00
AUTHOH=nON TOTAL FEE ( CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED [CIBTIN6 DWELLING I�}�}�p I��
TO THE PUBLIC SEWER APPHOWIS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF-19—
OWNER
F IB_OWNER OR NEW HOUSE SEWER
OW NERD AGENT_ CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PITS°)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ANO/OR DRAINFIELD
AND STATE THAT THE ABOVE It CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STAT LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY TH♦ A PRO LY OIBTER£ AMU OR ALTCA REPAIR SEWER Ow
LICENSED AS REOUIRE L A [8 A STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA ON THAT AL R OF INTEND TO DISCONNECT PLUG AND
RESIDE IN THE A E N IA P Y ABANDON HOUSE SEWER
SIGNATURE ❑
OF PERMRT BACKFILL SEPTIC TANKS
SEEP PIT(G) ❑ CESSPOOLS
OVAMATION JACK R ALLEN
GK M O CASH SUPERVISING MECHANICAL ENGINEER
LhL,o6 4 0 2zS SEP13 1 0 A 7.A00- Q