HomeMy Public PortalAbout9830 VAL ST_Sewer__ Lio Z t✓,
sAmseall55 APPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
D'°m "wit of County Engineer
County of Los Angel" BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
m CASSATTD GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL. IN c OR ST v
LEGAL OWNER
DESCRIPTION LOT NO
/ �G c� MAIL
BLOCK TRACT / ADDRESS
SIZE OF LOT d S NO OP BLT CITY TEL NO
NOW ON LOT Z
USE OF DISTRICT NO GROUP MAP BUILDINGS
BK PO
CONTRACTORb 711
ADDRESS I f �^ CONNECTION DATA /..�
STATION DEPTH
CITY TEL NO14, - MANHOLE REFERENCE
9--STATE / (LOWER
REGISTRATION NO(�- ❑ COUNTY
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
TYPE OF C1{F{(=ttION LENGTH FROM
PUBLIC SEWER O S3 SO Y FURE7 P L Y L TO P L
SEPTIC TANK SEEPAGE PIT OR 0�
PITS AND/OR DRAINFIELD 0 S 3 GO
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL DRYWELL MANHOLE 0 S 200 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 0 S 100 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WONK TO HOUSE SEWER 0 f 1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM 0 S 1 DO WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS PERMT s 1 00 n
REIMBURSEMENT FEE `-
AIITHO HIS DAT A TOTAL PEE O APPROVALS
wT DATE INSPECTOR SSIGNATURE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- efa.S
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER D C y NEW HOUSE SEWER
SIGNED THI AY OF 19
s�[� CONNECT ADDITIONAL`
OWNER OR BUILDING OR WORK
OWNERS AGENT SAND/OR
BSEP PITS)
ADDRESSAND/OR DRAINFIELD '
r
I HEREBY OWL GE THAT 1 HAVE D THIS AP CATION C�POOL❑ DRYWELL❑
AND STATE AT THE ABOVE IS CORRECT AND AGREE T COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AY THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS Ck
SIGNATURE SEEP PIT(S)❑ CESSPOO
OF PERMITTEE /
JOHN A LAMBIE COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
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