HomeMy Public PortalAbout5430 WELLAND AVE_Sewer__ PL C]T
8A842D APPLICATIO.. FOR PERMIT
-�
seae a-sa COUNTY OF LOS ANGELES7
SEWER-SEWAGE WSPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS .
JOHN A. LAMRIE. County Engineer "—
CASSATT D. GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN
CROSS ST.
LEGAL =--
DESCRIPTION LOT NO. OWNER
BLOCK TRACT e MAIL
ADDRESS
NO,OF BLDGS. _
SIZE OF LOT "- NOW ON LOT CITY - TEL. NO..
USE , DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
BK PG
CONTRACTOR -'..._ �,..�'�
-- �
ADDRESS _ " ,,'> 4,y CONNECTION DATA
CITY - TCL.N0. STATION •''' '"' DEPTH
STATE MANHOLE REFERENCE " �>.-. "UPPER
REGISTRATION NO F COUNTY ' LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Com._13.00
TYPE OF CONI,�ECJUN LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CU B - P.L. M.L.TO P.L.
PITS AND/OR DRAINF!ELD @ $3.00 ,r
OVERFLOW SEEPAGE PIT.DRAINFIELD
ExTN_CESSPOOL.DRYWELL C? $2.00
HOUSE SEWER CONNECTING TO g' -a ;° P.C.N0,
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. N0. JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT N0. � •'j
WORK TO HOUSE SEWER 'SLOO .I r
AL'T'ER, REPAIR OR ABANDON HOUSE,/' J STATE ENCROACHMENT
SEWER OR DISPO -L-•SYSTEM !;' $1..00 PERMIT NO.
N
INDUSTRIAL -
- WASTE APPROVAL
_ CHARGES
OWNER'S PERMIT -2-r"-0a " CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NCON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXIISTINGAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS—DAY 0F, 19— NEW HOUSE SEWER
OWNER OR J CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK _ Ie
ADDRESS SEPTIC TANK,SEEP.PIT($) 7
- _AND/ORDRAIN.FIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 1S CORRECT AND AGREE TO COMPLY CESSPOOL 0 DRYWEL_L ❑ _ '
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. ALTER,_EPAIR,AE SEWER
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES CQUNTY---AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL s;)5"- �f4ER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. �, BACKFILL SEPTIC TANKS
SIGNATURE s•-; a,'/ s - SEEP.PITS) } CESSPOOLS
OF PERMITTEE
sF VALIDATION ROBERT A. WOOD
CR. K.0. CASH SUPERVISING MECHANICAL ENGINEER
L"19148Q AUG2111 0 250
G: :II 66 (G_u2 r
/6A&42[) �.�'PL,iCATiC�f4 FUR PERiWi`l' l�J
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BJ ILD I NC �
TJOHNJOHNA. iAM.l3ZE, County 1<ngaTTeer -ADDRESS
WILLIAM A. JENSEPI. aup't of Building y.
LOCALITY
NEAREST _-
FOR APPLICANT TO `ILL IN
ROSS T `------
OESCRI1,11ION t..CT NV ; OWNER
/ MAIL.
TRACIBL.iCK ADDRESS
.; f f-s
hf 0. OF HLDGS.
!.?E: OF r_ NOW ON ',_OT - CITY TEL. NO.
BU!LU.NCS DISTRICT NO. GROUPJ. M.AP PROCESSED BY
BK PG
CON', CTOR
_s � -4-
ADDRESS
4ADbrt S> ' ' _ ; , ..,,;,r ,�� d CONNECTION DATA .
C..[.1. ,./ :l y,L N # i`" S AT70N �'Y .r DEPTH -
STATE MANHOLEF. FEREY E € UPPER _
REI,IST A'lIJ'd P F- L}/COUNTY- '�/� v; V'= taVS't-iT'
>:_. -
NO.� 1.S Cft'PiiOhJ Jr'� WOKiK TEE _ _ -.`i.:Y,E Or CCINNE.�TkbN i.EN G THF M
OU. € 9 4lrtR CONN LCTING 70 I Y CURS' I'.L. M.L.TO P.L.
l L
1 PUBLIC`'SEWER @ $a'.OD
t a
- P.C.--t 4 JO U
T'
P7t4.TANK SECI'hCE P T (?F? _
FIT AND!
OR OR PRA N IE D @ $10.00 'I CJ.IMP, NO //� ..�° P` ,JB N0.
ri J- S YSER CONN1:G T!JQ' Y
r'ISI!',A?F.OIS OSAt .SYSTEM � I TRUNK PERMIT Yd'J. ROAD PERMIT NO.
ao.rxQ I
--. - - --- -- -- - - - - -- -- ---— - - --- -
C'NrxEC7 yDLITIONAi.O�DC OR __-, T - ___�. U
AF FIbAYIY w,asvE¢�EA;.¢fs4 kT I RECORD,iNSTR i��i0. DATE
WORK TO HOUSE SEWER F .OQ � I � I I 1 CL
MERFLIW S EPA EP f C,RAINFIEL �__-.- !_. -- �
-_-
%CN.CF S OCL DRYWELL,.M NfSULE C $5 00 z
-.__. .._
HWY. OR ST WIDENING
SEW .$'3.00 _._.. - _-__-
A PLR,R 'AIR-UR ABANDON HOUSE
n O[.LI SP 4T'SM � �. STATEENGROACH `ENT
_-- ---` I PERMIT NO,
I
WASTE APPROVA
-CHARGES
OVMER'S PERMIT 2' 00
TI ! 1 -
CONNECTION CHARGE PEE
�TAIF��AU
AUTHORIZATION{I
! HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-. FCEIMBUR EPi e.NT FEE
TRACT R TO CONNECT THE ABOYE DESCRIBED EXISTING DWELL!NG
T4 THE PLIULIC BEWER, APPROVALS DATE ' INSPECTOR S,..1•GM,$IURE:
SIGNED
OWNERTH.iS`-----CYi4Y-O ',�-----'_ —__— ------- - —-_ ------- ---------
OWNE;OR t NEW HOUSE SEWER -
OWNERS AGLH'f,_,,,____
CONNECT ADDITI ONAi.. �
' BUILDING OR WORK I•
-._. _-_ _._-___ _Jf-
SEPTIC YANK SEEP PIT'($)i {
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THII' APPLICATION AND/OR DFAINF E.LD i
AND STATE THAM THE. ABOVE IS CORRECT AND AGREE TO COMPLY - -__.._-- -__- - ---.___-.�_�____��____-_..-_..._.__
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING _-__-____._
PLSJ MaIFNG AND SEWERS CESSPOOL El DRYWELL
F HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR.SEWER OR
i
LICENSED AS REQ UIREU, Bl` LOS' ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM I i
CALIFORNIA OR I Al' I AM T14E LEGAL owWffr',.OF, AND INTEND TO/
DISCONN C, PLUG AND i.
RESIDE IN, 'iHP: ASON_` DESCRi BED P.E9 D#NTI.ALtPROPERTY.
� ABANDON kO.JSk SEWER
SIGNATURE
{3F pERMITT'EE BACKF' LL SEPTIC.TANKS
srcP,PITS) F-I C"ZPOOLS
_
VALIDATION ROBERT A. WOOD
C M.o. CASHr. S!JPERVISING NIECHAN;CAL ENGINEER
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