HomeMy Public PortalAbout6433 TRELAWNEY AVE_Sewer__ Iy 54 APPLICATION FOR PERMIT - -1
DMSION OF BUU ING AND SAFETY SEWER—SEWAGE DISPOSAL
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County Of LOB ASzgll BUILDING L+
WM J FOX COUNTY ENGINEER ADDRESS
CASBATT O GRIMM SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST /1- ,E:,Awl LJ
CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER Q .B
BLOCK TRACT 2 7 b MAIL a-_k
'7 (� I ADDRESS Ifi
S12E OF LOT /O I T"cp XOWOON LOTS
CITYrmQ TEL NO
BUEIDINGS OF HS
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CONTRACTO je 4 A(te l` I-I a S 0 III J
ADDRES 3 p6Mp L E AIE. CONNECTION DATA
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CI G STATION DEPTH
(SI !OJ MANHOLE REFERENCE
REGISTRATION NO /c:JOAF a 00 ❑ COUNTY
Lamm
TYPE OF CONNECTION LENGTH FROM Y'D
NO DESCRIPTION OF WORK FEE .► CURB lowM LTO P L IC J
HOUSE SEWER CONNECTING TO
PUBLIC SEWER ® S S 50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR CO IMP NO /� 77 JOB NO
WORK TO HOUSE SEWER 1 00 /
ALTER OR REPAIR EKISTING Iy O
SEWER OR DISPOSAL SYSTEM i DO TRUNK PERMIT NO ROAD PERMIT NO A
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD S 00 INDUSTRIAL
CESSPOOL-DRYWELL -- WASTE APPROVAL
SPECIAL CONDITIONS ONLY E 00 CHARGES
OWNEW S pEPIN= CONNECTION CHARGE FEE
S 1 �00—
AUTHORIZATION TOTAL FEE :v REIMBURSEMENT FEE
TRACTORHAVE TTOS CONNECTDATE ONTRTHEAABOVECTED WDESCR BEDITH THE H EU I STINGIN A DWELL NGCON APPROVALS GATE INSPECTOR 9416HATURE
TO THE PUBLIC SEWER
SIGNED THIS 17AY O• Iyy�ys NEW HOUSE SEWER 12
/D'63
OWNER OR CONNECT ADDITIOAL
OWNERS AGEN BUILDING OR WORN
SEPTIC TANK SEEP PIT($)
ADDRESS_ AND/OR DRAINF15LD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ TH4 APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LE QAL ` ER OF THE ABO ABANDON HOUSE SEWER
DESCRIBy RfiB1OENTIAIPP C T
/ i%� 9SE
_� C S
SIGNATURE '
OF PERMITTE
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WILLIAM J. FO COUNT'ENGINEER VALIDATION
BY —Y00 VY7 21S -M 7 4 4.50 D
DEPUTY DEPUTY ^/
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BY BY
',m Depun DEPUTY