HomeMy Public PortalAbout5442 WELLAND AVE_Sewer__ E80A2D APPLICATION FOR PERMIT.
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING y� r
RES
JOHN A. LAMBIE, County Enginosr ADDS
CASSATT D. GRIFFIN, Supt of RufldiW LOCALITY 7 S K...
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNER
DESCRIPTION LOT N0. -
BLOCKTRACT MAIL
ar { t4 ADDRESS " 1 ._
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT - CITY TEL. NO.
USE OF w__-:v `
BUILDINGS 1.;' - DISTRICT NO. GROUP MAP PROCESSED BY
CONTRACTOR —� BK PG I
ADDRESSc- �- CONNECTION DATA
CITY 'e TEL.N0. ,xi - STATIONDEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION N0. 1 �% COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
Y HOUSE SEWER CONNECTING TO
4 PUBLIC SEWER CO) $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
HOUR[VSE SEWER CONNECTING TO P.C.NO.
PATE DISPOSAL SYSTEM @ $1.00 CO. IMP, N0, JOB NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT N0.
ALTER,REPAIROR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
CHARGES
�t
OWNERS PERMIT g 2. 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE I 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 DAYF 19_
S� NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT -` -' - BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP. PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT IHAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL EI DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
ED CERTIFY THAT I 9 GELESRI�C REGISTERED AND/OR DISCONNECT PLUG AND
Ll SED AS REQUIRE LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
C [FORK OR THAT i M THE LEG tf OWNER OF THE AIIOVE
DE RIB /�@€SIDENT[A ERTY BACKFILL SEPTIC TANKS
S, R�"''-: -.;,.-yo1„��, SEEP.PIT(S) ❑ CESSPOOLS
OF ERM1 E
a,
�P VALIDATION ROBERT A. WOOD
CL Y.D...- CA5;1a SUPERVISING MECHANICAL,ENGINEER
"g`2D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
IOlfrr A. LAMBIE, County Engineer _
CA BTT D. GRIFFIN, Supt of Building
ADDRESS T
LOCALITY
NEAREST +�
FOR APPLICANT TO FILL IN CROSS ST. .f t
LEGAL "
DESCRIPTION LOT NO. _OWNER �5— •,
BLOCK TRACT P'� &' MAIL
9 ADDRESS
O,O?'BLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF q.:_----
BUILDINGS `, ..dz. DISTRICT N0, GROUP MRP PROCESSED BY
BK PG
CONTRACTOR �--"`� 4 w•
ADDRESS CONNECTION DATA
CITY a TEL.NO. STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. ' !F ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK I 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, JOB NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT N0..
AL.TER.,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT N0.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ z CIO CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 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 r — "" BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT 'THEE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL El DRYWELL 0
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. k SEWAGE DISPOSAL SYSTEM
I WIMEBY CERTIFY THAT I AM PROPER REGISTERED AND/OR
U f P1SE0 AS REOUIR LOS ANGLE COUNTY AND STATE OF DISCONNECT PLUG AND
C IFORNLA OR THAT I M THE LEG OWNER OF THE ABOVE ABANDON HOUSE SEWER
D ER.,r1BE'$ RESIDENd1A OPERTY. �''"-' BACKFILL SEPTIC TANKS (]
Iv/ UR SEEP.PIT(S) ❑ CESSPOOLS
OF PERMIT E
ALIDATIONROB�R r A. WOOD
CK. M.G. "CASK. SUPERVISING MECHANICAL ENGINEER
rs € ii x
£