HomeMy Public PortalAbout5310 WELLAND AVE_Sewer__ tF1A8d.2q APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION fAILDING / }
DRESS I l d. 1
JOHN A. LAMBIE, County Engineer --- 2_. L__.; — — --_—..—_—^---
WILLIAM A. JENSEN, Su.p°t of building
LOCALITY
ARES,
CROSS ST. ,� �y"' ,-"
FOR APPLICANT TO FILL I.1V —_---_ --} 1 �_-_ ---_---
L G /f J
D'E,CR I,0N LOT NO 3 OWNER
x-" MAIL
BLOCK 7- -PACT d ADDRESS
_DODO.
NO. Or 3L'G S. II
SIZE ;F L^T NNW O'V LOT' !9 CITY TEL. NO.
u:E OF'
d DISTRICT NO. GROUP MAF' PROCESSED BY
B:ILOI'4GS t�" PG.
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CONTRACTOR
ADDRESS CONNECTION DATA
CITY y j 3/ g :y „� TEL. NO, i ± ri•`. STATION ? .e"�i >�.: DEPTH
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REGISTRATION NO !�� ;L'� ❑
STATE
MANHOLE REFERENCE' j�''��r-f ,�i �9f 4 i --LOWER �
0NO. I DESCRIPTION OF bJ0RK F'EE a'` 7YYPE OF CONNECTION LENGTH FROM
_ _..- -__DODO
+ HOU5E SE_WE�:CONNECTING TO _ "P r CU R37 P.L. MA..To P.L.
I Pl 8l IC SEWED
r
-_ _-
SEF TI..TANK EiPAGE PIT OR .1__.-_ L
' CO:IMP.NO.
tf AND/ORD/OR DRAINFIELD � $t0.00 _.-__� - _.tOB..-___NO.
-_.-__ _ -__
I
IiOUSE SEWER SAL "f
$3.00 SYSTEM NESTING 'O
PRIVATE DISPOSAL TRUNK PERMIT NO. ROAD PERMIT NO. / - (.J
� -
_._._.-_ -.. _.__.._.
CONNEC A(DO
ITiNAL 9L—DG-0R- AFFIDAVIT i wntvrx ea5E#Ekr RECORD.1NSTR.N. i_ DATE
WORK TO HOUSE SEWER @
- ..$3.0.4
-RAINFI61LR __OW g=EFAV;Plr,D -LD - _-
-_L
1 I
--�___._
EX,N:,€:EhSF OOL,DRYW ELL.MANHOL,E@ $5.00
__-_DODO __.-..._ HWY.OR ST.WIDENING
AL7EFt,REPAIR OR ABP ND ON {pU5-^_ ' '
EWER OR DISP05AL SY5'TEM $3.00
-._-_ SE
_DODO__ .__-.__ STATE ENCROACHMENT
I PERMIT NO. -
_.
_, -.-- WAS rE APPROVAL
J. PERMIT CHARGES
6JYY lY L.R�
2� 00 -..—._. -.--- -- _,..
'___ 1 -.-- CONNECTION CHARGE PEE
AUTHORIZATION TOTAL FEE � ------- ---- --- - - --- ---- ----
1 HAVE'. AT THIS DATE ,A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEETRACTORTO CONNECT THE ABOVE. DESCRIBED F_k!S'r1iVG DWELL-INC --_--____- _.-._...__-___
TO THE PUSLIC SEWER. - APPROVALS DATE j INSPECTORS.SIGNATURE
5.IGNED THIS DAY OF"._.--- - —99--
OWNER OR NEW HOUSE
.-_ -z--- SEWER
- . -&------ -_I'..-� _..
� -OWNERS AGENT__ _ONALCONNECT ADDI ---_ _--__--.-_-'
BUILDING OR WORK II
sE,YT(c TANK.SEEP,PlrISa I
I NSTATE THAT
THF AG.E THAT ! F{ECAVE A-NO THIS APPLICATION
COMPLY
A.ND.OR DRAINFIELD
AND TATE THAT 'THE. :h e90VE IS CORRECT AND AGREE TO COMPt_Y ___--__�_-.-.-_�___��.--
WIT„IALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SCWE:RS. CESSPOOL ❑ DRYWELL
t
HEREBY CERTIFY THAT I AM PROPERLY REGIS')'E REA ANG/Oft ALTER,REPAIR,SEWER OR-- f---�--- ---_ _—_---
LICENS.EDAS REQUIRED BY L,6S ANGLES COUNTY'AND STATE OF SEWAGE DISPOSAL SYSTEM I
CALIPORN IA OR THAT I AM,,.tgE LEGAL OWNER OF,=AND INTEND TO -.-.--'.-
DISC OI. NECT PLUG AND
RESIDE' IN, THE ABOVE D,.FSQ'RIBED RESIDENTIAL-PROPERTY. I
ABANDON N0iJSE SEWER
SIGNATUREODOR._
B [�
OF PERMITTEE BACKFILL SEPTIC TANKS y.„j '� � - --___
SEEP,PIT(S1 El CESSPOOLS
---VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
C.1)1,. M.O. CASH