HomeMy Public PortalAbout5351 WELLAND AVE_Sewer__ :E808 3-81 t
6A$420 APPLICATION FOR.'PERMIT
COUNTY OF LOS ANGELES SEINER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION n®RE sG ''
JOHN A, LAMBIM County Engineer
WILLIAM A. JENSEN, Supt of Building LOCALITY y �
FOR APPLI TO FILL IN NEAREST
CROSS sr. ,
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS
NO,OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT N0. GROUP BIC MAP @G PROCESSED BY
CONTRACTOR
ADDRESS CONNECTION DATA !
clrY �°°' ,,,. ' TEL.NO. � ''�� :•1 = .+TArpaly '"''• , � �; DEPTH
REGISTRATION NO.
f ' TE MANHOLE REFERENCE
COUNTY
NO. I DESCRIPTION OF FEE
HOUSE SEWER CONNECTING TO C. �;
PUBLIC SEWER @ $3.00 TYPE OF CONN ECT(0I� LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. C / f"P,L> M.L.TO P.L. - �v
ITS AND/OR DRAIHFIELD @ $3.00 r .
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL,DRYWELL @ $2,00
HOUSE SEWER CONNECTING TOr P.C,NO. O
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO,° JOB N0.
CONNECT ADDITIONAL.BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.`�%
WORK TO HOUSE SEWER $1,00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT SEWER OR DISPOSAL SYSTEM @ $3.00 PERMIT NO.
INDUSTRIAL tiJ
WASTE APPROVAL
tI>
CHARGES Z
OWNER'S PEAT $ 2 QQ CONNECTION CHARGE FEE.
AUTHORIZATION TOTAL FES : -i.g` REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATEINSPECTOR°S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 13 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS _ _- -_- _ SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS, CORRECT AND AGREE TO COMPLY CESSPOOL Q DRYWELL
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,-3 AM '�E L�G(4L OWNER_�OF (E ABOVE
DESCRIBED RESIDEN L ROP,EB1'Y. ,1;� �i,,-> ; BACKFILL SEPTIC TAf�KS (]
SIGNATURE -- -�
y- SEEP.PIT(S) CE85POOL.S .
OF PERMIT 'z-
VALIDATION ROBERT A. WOOD
CK, li.4. GSH SCI"esERVIISING MECHAAIiC:AL]ENr.INEER
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:E80R3-51
6A5d20 APPLICATION FOR PERMIT
'
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING_ ` , i
IOl"SPT A, LAMBIE, County Ens�aeer ADDRESS �
WILLIAM A. JENSEN. Sup't at Building LOCALITY
NEAREST � r ��"
FOR APPLICMff TO FU I. IN CROSS ST,
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT y MAIL
a ADDRESS
NO.OF BLDGS.
SITE OF LOT NOW ON LOT CITY TEL. N0,
USE OF
BUILDINGSDISTRICT N0. GROUP MAP P CF�SSED BY
SK peCONTRACTOR
ZZ.p e
ADDRESS ; -' CONNECTION DATA
CITY %.;•' ty TEL.N0, iWATION /_ DEPTH
j [J STATE MANHOLE REFERENCEI ._ UPPER
REGISTRATION N0. t '� _ [] COUNTY ¢' �.�- LOWER
N0. I DESCRIPTION 05 ORK FEE
OtJSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE_.OF CO NE¢TTiON LENGTH FROM
SEPTIC TANK,SEEPAGE PCT OR Y. > P.L. M-L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL E) $2.00 M
HOUSE SEWER CONNECTING TOP.C.NO. 0
PRIVATE DISPOSAL SYSTEM °CT ST= Co.INP. NO, ,JOB N0. �
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT
WORK TO HOUSE SEWER $1.00
ALTER,REPAIR OR ABAND'OWHOUSE STATE ENCROACHMENT - 0
SEWER R DISP05 SY9T :I# @ $1.00 PERMIT N0.
Ld!
�' ✓' { INDUSTRIAL d
WASTE APPROVAL �y
CHARGES Z
OWNER'S PERMIT 3 __.-e-00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE `A REIMBURSEMENT FEE
I HAVE AT THIS DATE A WITH THE HEREINCON-
TRACTOR TO CONNECT THE ABOVETDESCRIBED EXIST NGAMED LS DWELLING APPROVADATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19� NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT -- —- -- - - BUILDING OR WORK
ADDRESS. SEPTIC TANK,SEEP.PIT($)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL DRYWELL
.WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS, SEWAGE DISPOSAL SYSTEII
I" HEREBY CERTIFY THAT I Ate PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY A D STATEOF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I ANI T E LF,GAL Or', ER :THE ABOVE
DESCRIBED RESID�L,P .4PERTY./' BACKFILL SEPTIC TANKS []
SIGNATURE SEEP..PIT(S) 0 CES"POOLS _
OF PER�R TTE
_
VALIDATION Y ROBERT A. W60D
CK. .' 2.0. CASH SUPERVISING MECKANICAL ENGINEER
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