HomeMy Public PortalAbout6403 TRELAWNEY AVE_Sewer__ 566 8
- APPLICATION FOR PERMIT
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IIVIMON OF SUMMIG AND SAFM SEWER—SEWAGE DISPOSAL
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CONTRACTOR VAUEY
ADDRESS 8p/M EAST VALLEY BLVD. CONNECTION DATA
CITY RDSEMEAD TEL NO AT• STATION Of 3 I GA DEPTH
REGISTRATION NO /o0 7A- / ❑ COUNTY �B�/ MANHOLE REFERENCE LOWER
TYP NECTION LENGTH FROM
NO DESCRIPTION OF WORK FEE Y tune P L M L TO P L
HOUSE SEWER CONNECTING TOPUBLI �cz
HOUSE EWER ® 7 S SO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100 /I�!
CONNECT ADDITIONAL BLDG OR CO IMP NO F( 7 JOB NO
WORK TO HOUSE SEWER too __
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 100 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD t 00 INDUSTRIAL
CESSPOOL- ORYW ELL -- WASTE APPROVAL
SPECUL COGITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
OWNEWS PmtmT s 1 00
AUTHORIZATION TOTAL FEE 9770
REIMBURSEMENT FEE
I HAVE TRACTORTHIS DATE TO CONNECT THECTED ABOVEWITH THE DESCRIBED HEREINNAMED
DWELLING APPROVALS DATE INSPECTORS SIGNATURE
TO THE PUBLIC SEWER NEW HOUSE SEWER MquL ��
SIGNED THIS DAY OF 1SISai . QI
OWNEROR I CONNECT ADDITIONAL
OWNER! AGENT LA
BUILDING OR WORK
SEPTICTANK SEEP,PIT(61
ADDRES AND/OR GRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CSSSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE 19 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND SPATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT AY THS LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENT PROPERTY BACKFILL SEP C TANKS❑ 13
• SEEP PIT S CESSPOOLS
SIGNATURE
OF FERMI
WILLIAM J.FOX.COUNTY ENGINSYA =A&ATION
By -USBI 7 5rm X29 4 450 0
DEPUTY DEPUTY
BY BY
® DEPUTY Utr