HomeMy Public PortalAbout5441 WELLAND AVE_Sewer__ APPLICATION FOR PIfRMIT
COUNTY of LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPAI'MMENT OF COU' .TY ENGINEER 1
BUIt.i?INC ANIS SAF> °Y DIVISION BU'ADDRESS -
JOHN A. LAMBIE. County Engineer —
CASSAIT D. GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FIZZ IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT ) ° MAIL --
ADDRESS
y� NO.OF BLDGS,
SIZE OF LOT 27 NOW ON LOT CITYTEL. N0.
USE OF
BUILDINGS DISTRYCT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTOR _ - - �" � {•:'_
ADDRESS CONNECTION DATA
CITY TEL.NO. TATION rC,` r-, y i DEPTH '
STATE MANHOLE REFERENCE ,/
REGISTRATION NO. COUNTY }!.p` ( LOWER
ND. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO ` ^,
PUBLIC SEWER $ ,OO TYPE OF CONNECTION,' LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR ' =-S .:-F=-;-_P.L. M.L.TO P.I_
PITS AND/OR DRAINFIELD @ si.00 -
OVERFLOW SEEPAGE PIT,DRAINFIELD
_ E%TN.,CESSPOOL,DRYWELL $i.00
HOUSE SEWER CONNECTING TOP,C.NO.
PRIVATE DISPOSAL SYSTEM @ $1LOO CO.IMP.NO. �_ "J JOB NO.
CONNECT ADDITIONAL BLDG.OR - TRUNK PERMIT N0. ROAD PERMIT NO.";;�
WORK TO HOUSE SEWER @ $1.00
ALTER:REPAIR OR AEANDON HOUSE STATE ENCROACHMENT -
SEWER OR DISPOSAL Sl"STEA! @ $ .00 PERMIT N0.
d INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHOMATION TOTAL FEE r/ REIMBURSEMENT FEE
I HAVE 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.
SIGNED THIS DAY OF 19- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT---"-:,-, BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP.PITS)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ❑ DRYWELL
❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,CESSPOOL L [3REPAIR,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 I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE ❑
SEEP. PIT(S)
[ICESSPOOLS C]i ' ::-OF PERMITTEE -r
}
9r VALIDATION ROBERT A. WOOD
C5. M.G. CASH SUPERVISING IdE:CHANIC.:AL, ENGINEER.
f T y
Z_ L`
APPLICATION'FOR PERMIT
be SEWER--SEWAGE DISPOSAL
:eea�a e•sa COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING
BUILDING AND SAFETY DIVISION ADDRESS
IOHN A. LAMBIE, CountT Eacine*dr
8 LOCALITY
CASSATT D. rgIFFIN, Supt of uildinQ NEAREST
CROSS -ST_--_ `�—•-----��
FOR APPLICANT TO FILL IN -------
LEGAL OWNE—
AIL
DESCRIPTION LOT N0. M
,+ ADDRESS
BLOCK TRACT ' ��
..N0.OF BLDGS. CITY
SIZE OF LOT NOW ON LOT tdAP PRQCESSED BY
PG-- DISTRICT N0. GROUP I B }
_ moi.
USE OF J
K
BUILDINGS
- 3 1 jr l
CONTRACTORS CO
NAIECTION DATA
ADDRESS.: - '- ,6TAT10N .. �! _ - >> .$ DEPTH -
L
UWE
_l... TEL.NO,/
CITY
O -•,.T. .. .
CITY STATE MANHOLE REFERENCE ,, l LOWER
COUNTY - -
REGISTRATION N0. FEE
No. DESCRIPTION OF WORK LENGTH FROM
HOUSE SEWER CONNECTING TO („a $3.00 Ty PE-0 ;CONN$C,T `lP M.L.TO P.L.
PUBLIC SEWER Y.
SEPTIC TANK,SEEPAGE PIT OR $3,00
PITS AND/OR DRAINFIELD
OVERFLOW SEEPAGE IT.DRAINFIELD @2.00 JOB 52.00 P.B NO.
EXTN..CESSPOOL,DRYELL CO.IMP.N0.
HOUSE SEWER CONNECTING TO @ $)00 ROAD PERMIT N10(
PRIVATE DISPOSAL SYSTEM TRUNK PERMIT NO.
CONNECT ADDITIONAL BLDG.OR @ $1.00
WORK TO HOUSE SEWER STATE ENCROACHMENT
ALTER,REPAIR OR ABANDON HQ'y9E @ $l 00 PERMIT NO..
SEWER OR ISPQSAL SYSTE INDUSTRIAL
r WASTE APPROVAL CHARGES
PERMIT . CONNECTION CHARGE FEE
OWNERS �'•`` i';F-' REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE '
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
DATE INSPECTOR'S SIGNATURE
TRATHERPUBLIC SEWER.TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVA
TO DAY OF I9----� NEW HOUSE SEWER
SIGNED THIS CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
ADDRESS
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APTO COMLY
PLICATION ALTER,REPAIR,SEWER OR
WITH ALL COUNTY ORDINANCES CORRECT
AND STATE LAWS AND AGREEREGULATING CESSPOOL 13 ORYWELL ❑
AND SEWAGE DISPOSAL SYSTEM
PLUMBING AND SEWERS. DISCONNECT PLUG AND
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR STATE OF ABANDON HOUSE SEWER
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND BACKFILL SEPTIC TANKS ❑
CALIFORNIA OR THAT 1 AM THE LEuAL OWNER OF SH: ABOVE SE P PITS) ❑ CESSPOOLS L�
DESCRIBED RES[DENTL,IL,PRQPERTY.
SIGNATURE = /
OF PERMITTE ROBERT A. WOOD
61N&J3R
:VALIDATION Usti suprutvislNG MECHANICAL IN
� K _