HomeMy Public PortalAbout5417 WELLAND AVE_Sewer__ y r
76 3-64
76A642D P9RM
FOR PRMIT
A64
COUNTY OF LOS ANGELES SEINER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADORES _
WILLIAM A. JENSEN, Sup't of Building
LOCALITY • _
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. I �'
LEGAL �}•'•�� J
DESCRIPTION
LOT NO. OWNER
MAIL �•9
BLOCK TRACT G7 �(.� ADDRESS �' J (�,7w�1—�,�� „��4*�•yyy����'
NO, OF BLDGS. -- —...-_/'/ 4fi r 1 •"3
SIZE OF LOT NOW ON LOT CITY (iL Y ` !���'�V TEL.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS a _ BK PG
CONTRACTOR ...��/ A! �' - G�--+J!✓—"
ADDRESSCONNECTION DATA
�/s DEPTH
CITY — 1L/.� TEL STATION
_ If /---L —�
{��T-"` '$"'�� ❑ (STATE MANHOLE REFERENCE UPPER
—
❑ COUNTY
REGISTRATION NO. ,,
NO. DESCRIPTION OF WORK FEE _ TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P,L. M.L.TO P.L.
PUBLIC SEWER ;5.00 P.G.NO. d
SEPTIC TANK,SEEPAGE PIT OR R CO.IMP.NO. JO8 NO.
PITS ANDLODRAINFIELD @ ;10.00 -- — O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO,
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT...BEONAL BLDG.OR ,w� AFFIpAVIT!Y1 ER 'AyeMExT�RECORD. STR.N0. DATE
WORK TO HOJSE SEWER $3.00L/�y//l'OVERFLOW SEEPAGE PIT.DRAINFIELDEXTN..CESSPOOL,DRYWELL.MANHOLE 0 $5.00 I - tL
LTER,REPAIR OR ABANDON HOUSE HR ST.WI E fc a,
SEWER OR D15POSAl SYSTEM __ $3.00 STATE_EINCRORCH MENT -
- _----- ---- -- -- PERMIT NO,
Z
— -- — -I--- INDUSTRIAL
WASTE APPROVAL
— CHARGES
OWNERS PERMIT _ S; 2i oo --
AUTHORIZATION TOTAL FEE ._tI CONNECTION CHARGE FEE --
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXI G DWELLING ---
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF
OWNER ORNEW HOUSE SEWER _ 4 -
OWNERS AGENT CONNECT ADDITIONAL
Q " -• ` 1'
BUILDING OR WORK
.ADDRESS _— - SEPTIC TANK,SEEP,PITS) -
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THEABOVE IS CORRECT AND AGREE TO COMPLY - -
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGI '"ERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY ND STATE OF SEWAGE DISPOSAL SYSTEM 7I—
CALIFORNIA OR THAT AM THE LEGAL OWNER F.
D INTEND TO DISCONNECT PLUG AND I
RESIDE IN, THS DESCRIBED RF,p'f9ENT L P OPE RTY. ABANDON HOUSE SEWER
SIGNATURE L/'iA/f( � BACKFILL SEPTIC TANKS ❑
OF PERMITT —._. --- SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATION--" " - ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH