HomeMy Public PortalAbout5427 WELLAND AVE_Sewer__ :ES4fi 3-61
6Afi420 APPLICATION FOR PERMIT"
COUP OF LBS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE;County Era lneex ADDRESS .:gym r _ �i �
WILLIAM A. JENSEN, Big°t of Building LOCALITY �•
NEAREST
FOR APPLICANT TO PILI. IN CROSS ST. v- '
LEGAL OWNER 6
DESCRIPTION LOT NO:
BLOCK TRACT — — MAIL �
ADDRESS .day� g ay�t
III).of BLD . ' .
slzE OF LOT NOW ON LOT TTY C- %�Y� �.T� NO,
USE OF DISTRICT N GROUP NmPItOCESSE NY
BUILDINGS
CONTRACTOR
H, Williams
.`
ADDRESS 2351 E. 118 y p,�a't�e a CONNECTION DATA
CITY TEL.NO. 64608 STATION DEPTH
[] STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. 139099 ❑ COUNTY LOWER
NO. I DESCRIPTION @F R FEE v
HOUSE SEWER CONNECTING TO
PUBLIC SEWER C $5:00 TYPE OF CONNECTION LENGTH FROM
PITS IACNDANK,SEEPAGE
EPA ELnT OR L� SS.ab Y° CURS P.L. WL,TO P.L.
OVERFLOW SEEPAGE PIT,DRJIINFIELD.
EXTN-CESSPOOL.DPYT @ $2.00
HOUSE SEWER CONNECTING`Ca P.C.NO® 0
PRIVATE DISPOSAL SYSTEM $1.00 CO.imp.NO. .POS N4. �3
CONNECT ADDITIONAL.BLDG.0R
WORK TO HOUSE.SEWER.' p SLOO TRUNK PERMIT N0. ROAD PERMIT EiO. 0
SE ERROR DA5PIOSRAA SvcTEHN HOUSE (oZ $1:00 STATE ENCROACHMENT dm
PERMIT N0,
INDUSTRIAL
WASTE APPROVAL
_ CHARGES z
OWNWS PERM s 2 000 CONNECTION CHARGE FEE
AUTHORIZA77ON TOTAL FEE t`;�' REIMBURSEMENT FEE
I DAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. -
TRACTOR. TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. — g®
SIGNED THIS—DAY ONEW HOUSE SEWER �
OWNER OR CONNECT ADDITIONAL -
OWNERS AGENT BUILDING OR WORK
ADDRESS----- _ SEPTIC TANK.SEEP.P T(S)
ANO/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT t HAVE READ THIS APPLICATION - - - -
AND STATE THAT THE ABOVE IS. CORRECT AND AGREE TO COMPLY CESSPOOL 0 DRYWELL
WITH ALL COUNTY ORDINA:NCE5 AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUVaiNG AND SEWERS. SELVAGE DISPOSAL SYSTEM
I HERESY 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 I AM THE LEGAL OWNER OF THE ABOVE BACKFILL SEPTIC TANKS �1
DESCRIBED RESIDENT'A PROPERTT.
� SEEP.PIT(S) CESSPOOLS
SIGNATURE
OF PERMITTEE
VALIDATI® >., ROBERT A. WOO
nM. V.0. CASN SUPERVISING MECFIANICLAL'ENGINEEW