HomeMy Public PortalAbout9751 VAL ST_Sewer__ GA64 4043 ,APPLICATION FOR PERMIT 975/ Y/�7L ST
C E808 D
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
,,.,,�, A LAMS= Comp �q�eB[r AOGRESe
WSLLIAM A. JKNSEN S.,7
of SuJdlDq
LOCALITY
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FOR APPLICANT TO FILL IN `"°a• •T
L
O[aCflIPTION LOT NO A OWNER
MAIL
BLOCK TRACT ADDRESS
F BL
SIZE OF LOT W ON LOT
CITY TEL NO
USE OR v
DISTRI
pU 1LDINOS CT NO I GROUP IRK YAP PROCESSED BY
CONTRACTOR . 0
(/ d
ADDRESSCONNECTION DATA
CITY [L NO d STATION [ O DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO COUNTY
No DESCRIPTION OF WORK E TYPE OF CO NNECTI ON LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB �L ML TO P L }
PUBLIC SEWER O Ism �f` �fQ.
SEPTIC TANK S[SPAG[PIT OR CO INF NO ✓� ✓ JOB NO O
PITS ANO/OR DRAINFI[LD O slow u
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM O ES OO 0'.
CONNECT ADDITIONAL pL00 OR AFFIDAVIT E[M[[ [y[w[ST P[CORD INQTR XO DATE O
WORK TO HOUSE SEWER O []OO (r`
OVERFLOW SEEPAGE PIT GRAINFIELD {LLJI
ALTERCESSPOOL O DRV W ELL MANHOLE O ES OO
ALTS ON DIS O wBSY TE OUSE HWY OR ST WIDENING yS
SEWER OR DISPOSAL SYSTEM O 53 00 BY
ENCROACHMENT
PERMIT NO
INDUSTRIAL
O��TYNWL.S WASTE APPROVAL PERMIT f 2 OD CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE F[[
I HAVE AT THIS DAT[ A CONTRACT WITN TH[ HCR[IH NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS A PCCTOR S SIGNATURE
SIGNED THIS DAY OF Iq_
OWNCROR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TARN S[IE Flryq
AND
STATE THAT TN[ ABOVE IS CORRECT AND AORC[ TO COMPLY AND/OR GRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRTWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG ANp
RESIOS IN THE A VE DQQ RIS[O PE IOENTI L PROM
ABANDON HOUS[t[WER
SIGNATUREBACKFILL S[ 'f1LC TANKS ❑
OP PERMITTEE SCEP PIT ISI U CESSPOOLS
VALIDATION ROBERT A WOOD
cK M o cwlH SUPERVISING MECHANICAL ENGINEER
LA�p 3 6 6 is MR20 1 O D 55,00" 7
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