HomeMy Public PortalAbout9855 VAL ST_Sewer__ f
:E808 90-63
BA642 L7 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION TAD
ING
JOF%ly A. LAi<4B%E, County Engineer
SSWILLIAM A. I£NSEN, Supt of Buildn gFOR APPLICANT TO FILL INyST ,�
L E C k L ,,rrrr /.,may
DESCR PTI:_1N LOT NO. OWNER --/-✓—+A'' ' - �� m"s',�y'
MAIL
BLOCKTRA.GT } ✓ ADDRESS
NO. OF BLDG S. - --_— - _--—.---�---.__
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF -p-'y � �
BUILDINGS .+rC C'y Di57RECT N]GROUP MAP R"ROCESSED F+Y
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CONTRA._TOR.
ADDRESS .."�e''�.� ��'�✓� �ss ��. a� CONNECTION DATA
- - �w - -- --- —" --- a --—
��p .� -ell
. STATION I - DEPTH
REGISTRATION
eS'. �A��^TCL `J 1. .�r"'.�,o� � e
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TATE -
NO d"�V9 w c" � �] COUNTY
MANHOLE REFERENCE.
GESCRIPT(CN OF WORK FEE TYPE.OF O*tV'FK TION LEN TH F'RO*A
HOUSE SEW ER CONN ECTi*!C-TO j Y _- #�-URB ?.:. Fe!.L TO p.L_
SEPTIC TANK,SEEMP NO PAGE PIT OR CO. -.,, P.C.NO.
I PITS ANO CSR DR.AINFICLD @ $}0,00 --_ r JOB td0. -_ y
- r HOU SE 5f WER.;ONN T I N G TO 7 TRUNK PERMIT NO. ROAD PERMIT NO.
YR VATE DISPOSAL SYSTEM 3.00 _. — !- -- aaAp»..•)
CONNE T ADDITIONAL BLDG UR AFFIDAVIT 1 *RIVER E1S5 MENT R.CO. INsTR.NO.— DATE
W C RK TO HOUSE EWER � �q
I,OVERFLOW SEEPAGE PIT,DRAIN FIELD
EXTN.,CE S?OOL,DRYWELI-.MANHOLF't - -
_._ - _.__ --- --_- HWY. OR ST.WIDENING
_..T A ER.REPAIR OR 48ANOON HOUSE I
5 WFR OR Di SP09AL SYSTEM ^03.00
STATE ENCROACH MEN7
P._,TM IT NO.
INDUSTRIAL
WASTE RPPRG4"A!.
CHARGES
OWNER`S PERMIT 3 211- oo --------------- ------ --..--- -------
_.--- ---- - CONNECTION CHARGE.FEE.
AUTHORIZATION TOTAL FEE � �_� __._ ---------------- - -----.-----------
'I HAVE AT TFI75 DATE'. A :CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRAC_YOR TO CONNECT' THE ABOVE, DESCRIBED EXISTING OW FEEING ---- � ®��L
TO THE PUBLIC SEW Erb„ � � ,.�� DATE 1 NSP EC TORS 51iNATU R=
SIGNED THIS DAY CF
OWNER OR f y NEW HOUSE SEWEROW
NERS AGE
'— ------ CONNECT ADDITIONAL
,.�• '� BUfLDING OR VV'RK
S'EP71C TANK,SEEP,PIT(S)
i. THAT
-_ --
1 HERE P�AKNOWLCtlGE TYY AST 1 HAVE READ THIS APPLICATION AND,'QH DRAINFIELD AND STATE THAT TI{E ABOVE IS CORRECT AND AGREE TO COMPLY --------------- -- ---- ----
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
'PLUMSING .AND SEWERS. CESSPOOL D DRYWEL.L [_! - -
i HEREBY CERTIFY THAT IAM 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 PI L AND
R E.S.ID9 IN, THE ABC DESCRIBED R'4'.'IDEhT1AL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE �,
OF PERMITTEE ��„�.= -sy Z� "r____ BACIIILL 56PT. TANKS
SEEP,PIT(S) D CESSPOOLS �fl
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. � M.a. •�A.sH
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