HomeMy Public PortalAbout9729 VAL ST_Sewer__ 76A 642D - C1606 - [/T! APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
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CRIPTION Lm NO /L ER
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MSE NO CLASS MANHOLE REI[R[NC[ 7 S LOWtR
DESCRIPTION OF WORK FE[ TYPE OFCOM IOM LENGTH FROM
NOUS[[EWER CONNECTING TO Y Re P L M L TO P L
PUSLICS[W[R O $T OD
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O[PI M I C NO
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HOUSE S[W[R CONNECTING TO TRUNK PERMIT NO ROAD K11MIT NO
PRIVATE DISPOSAL SYSTEM O [300
CONNECT ADDITIONAL SLOG OR AFFIDAVIT I RMw[I 11T[0[1R RECORD INSTR NO DATIC
WORK TO HOUSE SEWER O Sb 00
OVERFLOW SEEPAGE PIT DRAINFI[LD O
[ITN CESSPOOL ORYW[LL O $I GO
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1 HAVE AT THIS DATE A CONTRACT WITH THE HER.,N NAMED CON R[IN[URSCM[NT I[[
TRACTOR TO CONNECT THE ABOVE D[SCRIBID EXISTING DWELLING APPROVA�
TO THE PUSLIC SEWER DA
79 I TORS
SIGNED THIS DAY OF 19_
OWNEROR NHOUSE
OW Me"AGENT CI[W MESU ADD[IETIOWERNAL
ADDRESS BUILDING OR WORK
SEPTICT•NK SEEP PIT(*)
I HERESY ACKNOWLE00[ THAT 1 MAK BRAD L
IGTIOM ANO/OR=114FI[LD
AN STAT[ THAT TX[
ABOVE Ib CORRECT AND ACOMILY
WITH ALL COUNTY ORDINANCES AND STAT[ LULATINO
PLU MSING AND S[W[M CESSPOOL ❑ DRrwE" ❑
1 HERESY CERTIFY THAT I AM PROPERLY REGAMO/OR ALTER REPAIR S[W[ROR
LICENSED AS R[OVIRCD SY LOB •NOLtS C NTreT[ 01 eCWAG[DIYPOBAurrt[M
CALIIGNIA OR THAT 1 AM THE LEGAL OWN 0TEND TO
RESIDE IN THE AEG D R D RESIDE IAL ABANDON
PLUG AND
ABANDON HDuec SEWER
bI ON•TUR[
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TBA 644 CEBOB-IO-TI APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALTY
FOR APPLICANT TO FILL IN NEARES
N":E BY
L r-
f
ttCRIPTIOry NO OWNER
MAIL LOCK TRACT AGGRESS
NO OF [LDGa
IZE OF LO NOW ON LOT CI TEL MO
CODISTRICT NO GROUP MAF EBBED BY
UILDINGSMex /fPaONTRAROR ✓ •v O _' /- — YO
ADOwua F C/ONNECT[ON DATA
CITY T[L ry0 xr
Me
STATION DEPTH
STATE LICUPPER
LICENSE NO CLASS MANHOLE EFERCNC[
Lowen
NO DESCRIPTION OF WORK MR TYPE OF NN[CTION LENGTH FROM
HOUSE SEWER CONNtRINO TO Y E P L ML TOP L
PUBLIC SEWER Y {T 00
SEPTIC TANK SEEPAGE PIT OR Pe
NO
PITS AND/OR DRA INFIELD Y 6000 CO IMP NO JOE NO
HOUSE EWER CONNECTING TO TRUNK PERMIT NO RMIT NO d
PRIVATE DISPOSAL SYSTEM 0 fS 00 O
CONNECT ADDITIONAL BLDG OR AFFIDAVITRNY[E .uulT RECORD INeYR N DATi V
WORK TO HOU et
SEWER Y Sam
OVERFLOW SEEPAGE PIT GRAINFIELD CIS
RATH CESSPOOL DRYW[LL O ES OO
ABANDON HOUSE HWY OR SR WIDENING O
SGMMMFBIFOISPOSAL SYSTEM C E3
00 OO STAT[ENCROACHMENT
MANHOLE 0 $T 00 PERMIT NO a
INDUSTRIAL N
��
E�}�p WASTE APPROVAL Z
OV;NEEt•S pEFjmT f ! 00 CHARGES
AUMOFMTION TOTAL FEF 6 O CONNECTION CHARGE FEC
I HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FES
TRACTOR TO Coi CT THE ABOVE DESC I [D 1 A OVA
TO THE PUBLIC S�(C�. DAT[ INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 1�
OWNER OR NEW HOVER SEWER
------ CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK BEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 MAV ROAD THIS APPLICATION AND/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STAT[ LAWS REGULATING ❑
PLUMBING AND SEWERS CESSPOOL ❑ DRYWILL
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REOUIR[D BY LOS ANGLES COUNTY AND STATE OF a EWAG E DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OP AND INTEND TO OISCON..CT PLUS AND
RESIDE IN TNC A OeecRIeLO J1[SIDC TIAL PROPERTY A BANDON HOUSE SEWER
.,.NATURE - --]
OF P[R.,BE �� BACKKILL SEPTIC TANKS ❑
SEEP PITIS) WPOO"
VALIDATION Cx M 0 CASH
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