HomeMy Public PortalAbout9610 VAL ST_Sewer__ ISamA;stl as APPLICATION FOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL 1
Npoimunt of County EnglnMSE
County of Los Angelos BUILDING
JOHN A IJAMBIE COUNTY ENGINEER
ADDRESS
m CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN cR RSEi
DESCRIPTION LOT NO we Lor # 3 I oAl OWNER C
BLOCK TRACT 24," I MAILADDRESS
XO OF BLDG
812E OF LO CITY TEL NO
� � NOW ON LOT
USILDINGS E OF DISTRICT NO GROUPSK YAP
BU _TRIC
CONTRACTOR V —A N► / /f�
ADDRESS CONNECTION DATA
��rj / STATION DEPTH
CITY TEL NO ph- a�7 fP MANHOLE REFERENCE q �T � � UPP
REGISTRATION NO .2 7 ❑ COUNTY f•I` ER
NO I DESCRIP1109 OF WORK FEE TYPE OF CONNECTI LENGTN FROM
02 IF
HOUSE SEWER CONNECTING TO Y CURB P L M L TOP L
PUBLIC SEWER @ S 3 SO
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR GRAINFIELD ® 4 3 00 c
OVERFLOW SEEPAGE PIT GRAINFIELD CO IMP NO ✓ JOB NOO
EXTN CESSPOOL DRTWELL MANHOLE S2 00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM S 100 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® S 1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM ® $1 00 INDUSTRIAL
WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERM s 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN f YEG CON- APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWERHERp '+ NEW HOUSE SEWER n
SIGNED THISDAY OF 19 CONNECT ADDITIONAL I
OWNER OR BUILDING OR WORK
OWNER! AG T AND/Olt
PIT(!)
ADDRE9 ANO/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ TX 9 APPLI ATI �ggppOL❑ DRYW ELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCE! AMD STATE LAWS REGULATING ALTER,REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AN THE LEGAL WHER OF THE ABOVE
DESCRIBED RESIDENTIARTY BACKFILL SEPTIC TANKS[I
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS
OF PERMITTEE
JOHN A LAMBIE COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF IGLBG INSPMCTOR
C[ Y O GFR
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AC':0II B! APPLICATION FOR PERMIT 1
DMSION OF BUUMIiG AND SAFM SEWER—SEWAGE DISPOSAL
Dsymbisnt of County Eughu se
County of Los Angeles BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
m CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN C....RT
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK TRACTct
MAIL
ADDRESS AHC
SIZE OF LOT
0 OF N BLDG9
ON
OLOT CITY RH4' TEL NO
USE
BUILDINGS DISTRICT NO GROUP YAP
BK P061 %
CONTRACTOR 7r
ADDRESS CO1NMEC17C DATA
CIT TEL NO STATION DEPTH
MANHOLE REFS ENCE UPPER
❑ STATE LOWER
REGISMATIfM O ❑ COUNTY
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF COX NE N LE N FROM
PUBLIC SEWER ® S S SO Y CURB L TO p L
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD S!00
OVERFLOW SEEPAGE PIT DRAINFIELD P NO
EXTN CESSPOOL DRYWELL MANHOLE ® S L 00 CO IMP NO JOB
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® S 100 TRUPERMIT N_OO ROAD PER NO
CONN ECT ADDITIONAL BLDG OR STATE ENCRO NYENT
WORK TO HOUSE SEWER ® $100 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUST%
SEWER OR DISPOSAL SYSTEM ® S 100 WASTE PROVAL
CHARGES
CONNECTION CHARGE FEE
Ovim's FEHMIT S 1 00
/ REIMBURSEMENT FEE
THyyvi
AUORIZATION 7TAL FEE ��V�
APPROVALS DATE INSPECTOR SSIGNATURE
1 HAVE AT THIS PATE A CONTRACT WITH THE HEREIN NAMED N-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING,DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTICTANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNT ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR 9EWEROR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AN PROPERLY REGISTERED ANO/OR pll
LICENSED AS REQUIRED BY LOS ANGELES COUNT CON NECT PLUG AND
AND STATE OF ABANDON HO PLUGUSE D
CALIFORNIA OR THAT 1 AN THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS❑
OF
PERMITTCEN
JOHN A LAMBIE COUNTY ENGINEER VALMATIO ROBERT A WOOD CHIEF PLBG INSPECTOR
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