HomeMy Public PortalAbout9616 VAL ST_Sewer__ 76A 642D-CtROB-1 0-7 1 APPLICA N FORr RMIT
COUNTY OF LOB ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS _` p.
LOCALITY T�E PL.
FOR APPLICANT TO FILL IN �.c��'T
LEGAL
[BUILDINGS
SCRIPTION LOTNO own[n DA tyx
IN
MAIL
OCK TRACT ADDRESS
IfD F_ . Vol_
NO OF SLOGS
II 01 LOT N ON Lor CITY E pL NO
[ oP
DISTRICTNO GROUP MAP PR S.ED By
BK PS `
ADDRESS w,-�,_ CONNECTI N DASA
CITY l QQn ,_AW CL No ,��j- SOS STAT ON DEPTH
(TATE // LIC MAN L[REFERENCE UPPER
LICENf[ NO I R.D� 44 6 CLABS LOWER
NO DESCRIPTION OF WORK FEE TYPE ONN[RIOn LENGTH FROM
HOUSE SEWER CONNECTING TO Y L M L TO PL
PUBLIC SEWER tl $7 DO NO
SEPTIC IAMM 6LCM0[PIT OR
IF
AND/OR DRA INFIELD 11000 CO IMP NO JO
MOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT N a
PRIVATE DISPOSAL BYBT[Y O tf 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT RMYRR IAT[R[KT RECORD INS" NO
O T[ V
WORKTO HOUSEB[W[R C tS 00
OVERFLOW SEEPAGE PIT GRAINFIELD
[[TN CLSSPOOL DRYWCLL C Saw HWY OR ST Wlp[NIMO W
ALTER REPAIR OR ABANDON HOU.[ O
SEWER OR DISPOSAL SYSTEM O S Co, STATE ENCROACHMENT
MANHOLE 0 $7 00 PERMIT NO O.
INDUSTRIAL
WASTE APPROVAL Z
O nwws CHARGES
Al FE9L'IIi • ] 00
AUTHOATLATION TOTAL FEE CONNECTION CHARGE FL[
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT IEE
TRACTOR TO CONNECT THE ABOVE OEGCRID90 E[ISTIND E&LLLIMO AFpAOVAIS
TO THE PUBLIC SEWER DAT[ INSPECTOR S SIGNATURE
SIGNED THIS DAY OF IY_
OWN[R OR [A-.--
EW HOUR[SEW LR
OWNERS ADEN T
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
BE"IC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATIONND/OR GRAINFIELD
AND STATE THAT THE ABOVE IB CORRECT AND AOR[[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND S[W[M [SBPO ❑ DRYW[LL
1 "REST CERTIFY THAT I AM PROPERLY REGISTERED AND/ORL PAIR SEWER OR
LICENSED AS R[OUIR[D BY LOe ,NGLES COUNTY ANO 6TAT[ OFLWA IfPOWLfYBTEM
CALF FORNI, OR THAT 1 AM T LEGAL OW OP AND INTEND TO
RESIDE IN THE A DSS IS[D RUIp[ TPA., PROKRTY ICCT RUO AND
HOUSE SEWER
SIGNATURE
01PIgMRTCECKFI'T f[P[IC T,SS ❑
•En TP[LI PlTlfl IJ CESSPOOLS
VALIDATION CK M O CASH
! �( 3 7 01473 OCT 23 I O D 6.00A 4
4 IIS
APPLICATION FOR PERMIT 'o
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
• ad Cour
County 0f room Angel" BUILDING T
JOHN A LAMBIE COUNTY ENGINZLrR ADDRESS ...y'' T�
m CASSATT D GRIFFIN, SUP T 01 BUILOINO LOCALITY
FOR APPLICANT TO FILL IN cRosRs s -7
LEGAL G
DESCRIPTION 'LOT NO OWNER r
/
BLOCK TRACT .� 1' i MAIL
1 , � I I ADDRESS !
NO OF BLDGS
SIZE OF LOT •moi NOW ON LOT L CITY TEL NO
USE OF ,�✓%
0 UILDIN 03 �- DISTRICT NO GROUP YAP
BK PG l
CONTRACTOR
ADDRESS CONNEC7I0ffi DATA
'STATION ..L V DEPTH
CITY
//Y TEl NO - • f MANHOLE RE ENCE I / LOWER
REGISTRATION NO / � V / (' / /�/ ❑ Coumw
No I DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
e
PUBLIC SEWER $.' B0. T CURB P L Y L 70 P L
SEPTIC TANK,SEEPAGE PIT OR
PITS ANO/OR DRAINFIELD ® $3 00
OVERFLOW S EPAGE PIT DRAINFIELD P C NO
EKTN CESSPOOL,DRYWELL MANHOLE 0 $Z 00 CO IMP NO J�-I � JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® S 100 TRUNK PERMIT NO ROAD PERMIT NO
CON NECT A DDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® III 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM 11 00 WASTE APPROVAL
CHARGES
Y CONNECTION CHARGE FEE
OWNER'S P®MIT s ^1 00
PEIYBURSEYEXT FEE
AUTHORIZATION xoTu t'Ee
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN HAYED CON- APPROVALS DATE INSPECTOR SSIGNATURE
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
OW NENS AGENT SEPTIC TANK,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 COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AY PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I All THE LEGAL OW E F THE ABOVE
DESCRIBED RESIDENTIAL PRO P SEEPPPIT(SEP(]SEPTIC TANKS 0 2-
SIGNATURE '�` '�
OF PERMITTEE
JOHN A LAMBIE, COUNTY ENG I EER/ ,. VALIDATION ROBERT A WOOD CHIME PLBG INSPECTOR
G{ Y 0 G'R