HomeMy Public PortalAbout5314 WELLAND AVE_Sewer__ 76A 642D-CE868 A-7/76 APPLICATION FOR PERMIT
SEWER—SEWAGE DISPOSAL.
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP BK MAP OCESSED BY
NG
ADDREPG
BUILDSS l `J�
CONNECTION DATA+
NEAR EST ST. f(� STATION – J DEPTH
CROSS ��� /� � kj`% UPPER
MANHOLE REFERENCE '' ,a
OWNER TYPE OF CONNECTION ~ LENGTH FROM
CURB P.L. M.L.TO P.L.
ADDRESS. _3J 7/MAIL L �a ,j �i� ( Y
-- yyyyyyP.C.NO.
75 �!y/
CITY�,j�j(� lt..f /J,,�•TEL. NO,C• T V CO.IMP. NO JOB NO.
LEGAL 9 TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.�af� •
AFFIDAVIT I wAlv[11 I [As[r[xT RECORD.INSTR.NO. DATE
BLOCK TRACT/0_I (,e)
NO. OF BLDGS.
SIZE OF LOT 7�� NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS
STATE ENCROACHMENT
_ - – PERMIT NO.
INDUSTRIAL
CONTRACTOR _ WASTE APPROVAL
ADDRESS n _ CHARGES V
01 CONNECTION CHARGE FEE
CITY TEL. NO. w
STATE LIC REIMBURSEMENT FEE 0
LICENSE: NO. CLASS I'—
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE !aJ
HOUSE SEWER CONNECTING TO 0-
PUBLIC SEWER @ NEW HOUSE SEWERN
SEPTIC lAN K.SEEPAGE PIT OR _ '__ Z
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK rp�
PRIVATE DISPOSAL SYSTEM @SEPTIC TANK.SEEP,PIT(S)
�I CONNECT ADDITIONAL AND/OR DRAINFIELD
f WORK TO HOUSE SEWER _ V
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL Cl DR-YWELL ❑ —}
EXTER,RESPOO R ABANDON
MANHOLE ALTER.REPAIR,SEWER OR j
ALTER.REPAIR OR ABANDON HOUSE SEWAGE DISPOSAL SYSTEM 1!
SEWER OR DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑
SEEP,PITS) ❑ CESSPOOLS ❑
OWNER'S Issuance Fee ffi 5�
I
HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AUTHORIZATION TOTAL FEE AND STATE THAT TME ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. PLUMBING AND SEWERS,
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
TO THE PUBLIC SEWER. LICENSED AS REQUIRED BY L05 ANGLES COUNTY AND STATE OF
SIGNED THIS DAY OF )9_ CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO
OWNER OR RESIDE IN. THE ABO DE5CRI BED RESIDENTIAL' PROPERTY.
OWNERS AGENT SIGNATURE
OF PERMTTTEE'
TION
C
CK., MO.O. CASH
4 7 9r
»AE-6C3 3-55 APPLICATION FOR PERMIT
&&E-65
DIVISION OF BUILDING ANIS SAFETY SEVER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING ,
WM.J. FOX, COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN,SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.,=- r.
—'
LEGAL
DESCRIPTION LOT NO, OWNER '
BLOCK TRACT MAIL
ADDRESS _
NO. OF BLDGS.
_SIZE OF LOT - NGl! ON LO? _ -_. _ CITY TEL..NO. �...
USE OF
BUILDINGS ' __ DISTRIC N0. GROUP MAP
13K PG
- CONTRACTOR
ADDRESS y t✓t� CCNNECTIC)IQ DATA
a
CITY
dTY : - ---- a ,„ T.
STA ION DEPTH TITI MANHOLE REFERENCE
REGISTRATION NO. 1/-
f?y,,.•f [] COUNTY �-
NO, DESCRIPTION OF WURK FEE
_ TYPE rCT;ON LENGTH FROM :.:
HOUSE SEVER CONNECTING TO - _ — L. 70 P
PUBLIC SE' ER_ _�� $ 3.''0 CURB � M.>6 { _ -- = ---. L.
HJUSE SEWER COI'1v EC CNG TO
PRIV.AT'c C SPOSAL SYSTEM 1.001 _ -- — --.
COdN'cCT ADDITIONAL BLDG. OR F C.NO.
r OUSE SEWER �_ 1.00 _ — _ CO<,_IR I_NOr JOB N(>,
ALTER OR OR REPAIR EXISTING
SEVER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT N0, ROAD PERMIT NX_`'�r�
_ DISCONNECT AND ABANDON SEWER
APiD,OR DISPOSAL SYSTEM
STATE ENCROACHMENT
PERMIT N0.
SEPTIC TANK,SEEPAGE PIT OR - _-- -- '— -- ---
— I PITS AND/OR DRAINFIELD 3.00 INDUSTRIAL
'-� - -
CESSPOOL-DRYW ELL WASTE.APPROVAL
_SPECIAL CONDPTIONS ONLY 2.00 CHARGES
OWNEWS PERMIT S I i. CONNECTION CHARGE FEE
00 -.— — �--
AUTHORIZATION TOTAL E -(` REIMBURSEMENT FEF-
I HAVE THIS DATE CONTRACTED WITH THfifEIZEIN N.MED CON- —
TRACTOR TO CONNECT T)j ABOVE DESC�ED if ING DW LLING APPROVALS _ DATE INSPECTOR`S SIGNATURE
T'0 THE PUBLIC Sp.l R f `y — ------
NEW HOUSE SEWER
SIGNED THI� DAY OF ;9 - --- `_
OWNER OR ,� ? CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
+' ._.SEPTIC TAN{,SEEP, PIT(S)
ADDRES3 '� �p' _ ANVOR DR-AVNFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE REAP 7f4ISyAPPLICATION CESSPOOL❑ ARYWELLO
AND STATE THAT THE ABOVE: IS CORRECT AND AGREE TO COMPLY
WITH Al"L 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- — - -- —
LICENSED AS REQUIRED By LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA CR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RiDN7t�.)s PFOP;;RTY �,�Q BACKFILL SEPTIC TANKS
SEEP. PIT(S) L CESSPOOLS
SIGNATURE - - ---�—i—
OF PERMITTEE J 9
WILLIAM J.FOX.COUNTY ENGINEER VALIDATION R.A.WOOD.CHIEF PL.8G. INSPECTOR
4