HomeMy Public PortalAbout5833 TREE ROSE TER_Sewer__ C"O°' °' APPLICATION FOR PERMIT
TSASAED COUNTY OF LOS ANGELES SEWER—SEWAgrE DISP SAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILD
JOHN A LAMBIE COUNTY ENGINEER ACC"•••
COLEMAN W JENKINS SUPT OF BUILDING
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LEGAL FOR APPLICANT TO FILL IN `.a •T
DESCRIPTION LOT NO -:37 OWNER
MAIL
BLOCK TRACT ADORES{
o OF SLOGS
SIZE OF Lorzl� Now ON LOT CITY TEL NO
Ust OF
DISTRICT NO GROUP MAP PROCESSED by
BUILD NOs
SR PD
CONTRACT r
r
ADD"ue CONNECTION DATA
RATION DEPTH
CI [L MO
STAT[ LIC /' //i— MANHOLE REFERENCE OWER
LICEN at
Mo, 4wf1 ` 7
NO DESCR I N O WORK P[[ TVP[01 CONN[RION l KOTII Fmom
HOUSE SEW{R CONNECTING TO �y,T Y CURS P M L TO P L a
PU°LICE[WER O Eeoo (/V PC MO
E[rtIC TANK SEEPAGE PIT OR co IMF No Joe No O O
Pm AND/OR GRAINFIELD O sl000 V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROM FEAR IT NO �.
PRIVATE DISPOSAL SYSTEM 0 ss 00 O
CONNECT ADDITIONAL SLDO OR AFFIDAVIT POr[[ lY[R[RT RECORD IMSTR NO DAT[
WORK TO XOU S[S[W[R 0 Q 00 !y'
OVERFLOW SEEPAGE PIT GRAINFIELD
[ETN CESSPOOL DRYWELL MANHOLE 0 Sam
ALTER PA ROR ABANDONHOUSEHWY OR 6T WIDENING N
SEWER OR DISPOSAL SYSTEM 0 ss 00 STAT[ENCROACHMENT
PERMIT NO
INDUSTRIAL
WARt APPROVAL
����p CHARGES
OTT1Tr.a s PMMT • z o0
AUTHORIZATION TOTAL FEF CONNECTION CHARGE FEE
1 HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMED COM "[IMSURSEMENTI[{
TRACTOR TO CONN CT TNS ABOVE D[SCRI°[D L[ISTIMO DWELLING APPROVAL)
TO THE PUBLIC SEWER DAT[ INSPECTOR[SIGNATURE
SIGNED THIS DAY OF 18_
OWNER OR NEW HOUSE S[W[R
OW Mt RS AO[N_ CONNECT ADDITIONAL
NILDINO OR WORK
ADDRESS SEPTIC TANK 8[[P PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR GRAINFIELD
AND
STAT[ THAT THE ABOVE IS CORRECT AND AOR[[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND STAT[ LAWS REGULATING
PLU MSINO AND S[W[M CESSPOOL ❑ DRYWELL ❑
1 HEREBY Ct RT1FY THAT I AM PR LY [°IST INTIM AND/ORI ALTER REPAIR SLW[ROR
LICENSED AS R[OUIR[D LEE NTY A BTATE or S[WAO[DISPOSAL SYSTEM
CALIIp11NIA OR TMAT T AL R OF INTEND TO GISCOMMLCT PLUG AND
R[SIG[ IM TX[ A "TIAL P[RTY ABANDON HOUSE SEWER
HONATUR[ BACKFILL SEPTIC TANKS ❑
or PERMM' S[EP PITISI ❑ CESSPOOLS
OVALIDj{IgON JACK R ALLHN
cK M o CASH
SUPERVISING MECHANICAL ENGINEER
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