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HomeMy Public PortalAbout5312 WELLAND AVE_Sewer__ :E808 10-63 6A6420 APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DtPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING ADDRESS JOHN A. LAMBIE, County Engineer WILLIAM A. JENSEN, Supt ©4 Building LOCALITY /'z- NEAREST CROSS ST. FOR APPLICANT TO FILL IN LE A L DESC RIPTION LOT NO. OWNER A— L 0 N A L A -- NEAREST R OS RE L ESS N T TG Y OWNER ER M L A I I, �SS BLOCK TRACT ADDIE TEL. NO. NO. OF BLDG SIZE OF LOT NOW ON LOT CITY USE OF r" DISTRICNO( R MAPROCESSED By _$UiL0 INGS T 'up P F3 K PG CONTRT AC OR ADDRESS CONNECTION DATA CITY - DEPTH TEL. N STATION D STATE MANHOLE REFERENCE REGISTRATION NO. COUNTY. L NO, UESCRIfTION OF WORK_ FEE. TYPE OF CONNECT16N H T'ROM H OUSE SEWER CONNECTING TQY. CURB P.L. M.L.TO P.L.. PUBLIC SEWER @ 8s.00 P.C.NO. SEPT.0 T NK,SEEPAGE P;7 OR 0 PITS ANO/OR DRAINrIRLO @ $30.00 CO IMP.No. JOB NO, HOUSE SEWER CONNECTING TO E TRUNK PERMIT NO. ROAD PERMIT NO. PZ VA7E DiSPOSAL SYSTEM @ 5:3.00 -i--NT-T RECORO NSTR. NO. DATE CONNE�7 ADDITIONAL BLDC. OR. FF WORK 1 0 HO ISE SEWER @ 83,00 OVERS' OW SEEPAGE PIT,0 lz- EXTN,-F55CjCL,ORYWFLL.MANHOLE -10 s- T 6 i ', P HOUSE HWY. OR ST.W1 NI G RO -MEN 'e'..vER Q4!- Q�S3 DO— STATE ENC AEH T PERMIT NO. /a I NOUSIR IAL WASTE AFPR CHARGEt OWNER'S PERMIT 2� 00 —r..—_- CONNECTION CHARGE FEE AUTHORIZATIO141 TOTAL FEE I H AVE: AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIPABURSFNIENT FF.=_- �ro TRACTOR C(NNE,(T THE ABOVE DESCRIBED EXISTING DWELLING TO F. —1 .9iGNATURE THE _U8 I C S E I'll 7 R. APPROVALS DATEINSPECTOR'S SIGNED THIS-----DAY OF�­--------I9— OWNER OR NEW HOUSE SEWER OWNE-S AGENT----..-----. NNECT ADDITIONAL ADDRE 15U 11-01 NG OR WORK SS- sE:PrIC TANK,SEEP,PIT(S) HFREBI ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR OR AiNFIELD AND STATE THAT 7HE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGUI-ATING B E CESSPOOL [-I DRYWELL PLUM INC. AND SEW_PS. HEREBY CgRT!FY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR SEWER OR LICEN9ED AS REQUIRED BY 08 ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM OR-4IA A OR THAT I AM THE OW 1 'IEND RALtFORI NER OF, AND N D TO D.SC6T�iNEZT'PL(G AND SIDE IN� THE �ROVE DESCRIBED REStDEN71AL PROPERTY I RTY. ABANDON HOUSE SEWER S:GNATURE - ' - I - .. .1, BACKFILL SEPTi C TANKS EJ SEEP.PIT(3) CESSPOOLS L VALIDATION_-- ROBERT A. WOOD SUPERVISING MECHANICAL ENGINEER CK. M.O. C AS H 7 j-