HomeMy Public PortalAbout5424 WELLAND AVE_Sewer__ EMPLE I ,F
'.80828.59 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBYE, County Engineer ADDRESS
C SSATT D. GRIFFIN, Supt of Building' LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. _
LEGAL y:
DESCRIPTION LOT NO. -- " OWNER
BLOCK - x TRACT MAIL
ADDRESS
NO.OF BLDGS. - - -�
SIZE OF LOT NOW ON LOTCITY .SEL. N0.
USE OF
BUILDINGS DISTRICT NO. G7UPMAP PROCESSED BY
-- .-,1 BK PG
� p`
CONTRACTOR J, "c grt�r
ADDRESS CONNECTION DATA a
CITY /`: ' TEL.NO...,: %. t STATION - �/ DEPTH
Y sy'
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. COUNTY LOWER
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB •;� : P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. NO. s JOB NO.
CONNECT ADDITIONAL BLDG.OR/
WORK TO HOUSE SEWER is "� - TRUNK PERMIT N0 ROAD PERMIT N0.5.00 E. '' �_ %'
ALTER.REPAIR OR ABANDON HOUSE L� STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEId @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT 5 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE �" REIMBURSEMENT FEE-1 A
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT TH.E-'ABOVJE DESCRIBED EXISTING DWELLING APPROVALS � DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER., -
SIGNED THIS-DAY OF 19_ NEW HOUSE SEWER 9
OWNERA
OWNERS AGENT CONNECT ADDITIONAL
- - BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 1S CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL, COUNTY ORDINANCES AND STAT£. LAWS REGULATING
PLUMBING AND SEWERS. ATTER,REPAIR.SEWER OR
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 CT PLUG AND
CALIFORNIA OR THAT j:�-AM THE LEGAL, OWNER_OF THE ABOVE
DESCRIBED RESIDENTI#L PROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE
SEEP.PIT(S) E3 CESSPOOLS El
OF PERMITTEE '
�a VALIDATION ROBERT A. WOOD
C&yi X.Q< CASH SUPERVISING MECHANICAL.ENGINEER
('.✓'fes
9-14 2g' AUG21 1 0 D 5.00- '
,4 41
76642
76A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION B tLOING
JOHN A, LAMM County Engineor ADDRESS ljlk,, J,"L
WILLIAM A. JENSEW, Sup't of Building
LOCALITY
EA REST
ST
FOR APPLICANT TO FILL IN CRCSSS
DESCRIPTION LOT NO. A,
MA:L
ADDRESS --v
Bi TRACT
N11, OF BLOGS
SIZE OF LOT & "NO. 1114 LOT CITY TEL, NO.
USE OF p pY BUILDINGS0- BK DISTRICT NO. GROUP AP PROCESSEDBY
_ __ P,
CONTRACTOR j4?j
J
J
ADQRFSSNECTIONIDATA—I-------
STATION I,- DEPTH
TEL NO
UPPER
STATE MANHOLE REFERENCE
T
,IST RATION NO. COUNTY LOWER
LOWER
. 0 P.L.—No, DESCRIPTION OF WORK FEB TYPE 0 CONNECTION FROM
LPYBLIC SEWER— .00 CURB P 0
SEPTIC TANK,SEEPAGE PIT OR
Prr5ND/OR DRAINFHELD I.33 NO
"ioUSE SEWER CoNNEC'illl TO "R 0
L SY5YEM $3.00 _t�59RMIT NO.
R
PRIVA CEG)SPOS�' -2
CONNE::T ADDITIONAL BLDG.OR AFFIDAVIT M NT RECORD.iNSTR.NO.�rT SE E DATE
WORK TO HOUSE SEWER @ S3,00
— — - - E-Cmt
COVER'FLOWS�FEOAGE P1 M,DRAIN
I:XTN.,CESSPOrL,E)RYWE'-L.MANHOLV.0 $5.00
HWY.OR ST.WIDENING
A(.X;��,-RLE+'A4rt )IR ASA N D 0 N HOUSE
SEWER @ $3.00 -------
STATE ENCROACHMENT
PERMITNO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNM'S $ 21 00
CONNECT 1ON C IAVCF FEE
AUTHORIZATIONT-
TOTAL FEE
I HAVE AT T141S DATE A CONTRACT WITH THE HE. IN NAME- CON- REInSQRSEM�£NTF
.' EE
F
RACTOR 0 CONNECT THE ABOVE: DFSC.F(IEIED �.X!STIN(�i DWELL G
TO THE PUBLIC SEVVElt, I APPROVALS DATE
.1 � 1 5
THIS DA iNBPECIOR'S SIGNATURE
SIGNED
Y 0 F--
OWNER OR
NEW HOUSE SEWER
OWNERS AGENI—A-tlwk NNECT ADDITIONAL
A
ADOREqd': BUILDING OR WORK
SrFTIC TANK,SEEP PFT(a)
HW
3 HEREBY ACKNOWLEDGE THAT,� AND
HAVE RE.Arl THIS APPLICATION /I OD
R RAINFIELD
A N D STATE THAT THE ABOVE 15 0 R RECT AND AGREE TO COMPLY
WITH
I.! AL- COUNTY E ORDINANCE,", AND STATE LAWS REGULATING
PI_`xi RING AND SEW RS. CS
ESPOOL [7j DRYWELL
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/'OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY L09 ANGLES COUNTY AND STATE OF SEWAGE.DISPOSAL SYSTEM
CA OR THAT I AM THE LEGAL OWNER OF. AND !NYEND TO __D�IECC�NN�� ----
P� rj: PLL C AND
FSir)E IN, THE ABO'k ES RILED R56IDENTIAL PROPERTJ.' ABANDON HO USE'SEWER
SIGNATURE
:
rFp IT -PT
OF PERMITTEEA'� TANKS
EE
S) CESSPOOLS
---'NVALIDATION ROBERT A. WOOD
L \:"
SUPERVISING MECHANICAL ENGINEER
j M.O. CASH