HomeMy Public PortalAbout5444 WELLAND AVE_Sewer__ IDEPAIC17MENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
- -- -- -
BUILDING _ NEAREST
ADDRESS ., --- '_ CROSS ST.
LOCALITY DISTRICT N0. SERIAL NO. PERMIT NO.
NEAREST A S
CROSS ST,
Je
- RECEIVED BY Ready for inspection DATE ISSUED
OWNER
MAIL __------------ ----___ .-�_
ADDRESS USE ZONE ' OCCUPANCY MAP
---- - --- --- -- -,-- BK PG
CITY TEL.NO.
CONTRACTOR
---------_._.__ �- -_ CO.IMP.NO.
ADDRESS
---- -_ - JOB N0.
CITY TE L.NO,
-- -.,----,_- - TRUNK PERMIT NO.
_'STATE
REGISTRATION NO. COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. STATE ENCROACHMENT
-- PERMIT NO.
BLOCK TRACT INDUSTRIAL
SIZE OF LOT N0.8F BLDG3. WASTE APPROVAL
NOW ON LOT
CHARGES
USE OF
BUILDINGS _ CONNECTION CHARGE FEE
NO.I DESCRIPTION OF VI/. RK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER @ $ 3.50 �, RECEIPT NO. I DATE I BY
HQUSE'SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 _ !
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO- DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
tSCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION DEPTH
CESSPOOL-DRY W ELL
SPECIAL CONDITIONS ONLY 2.00 ^- 'ANH9L£,^EFERENCE
UPPER < LQWrR
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT OO CURB r_. M.L.TO P.L.
AUTHORIZATION I TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THE PUBLIC SEWER APPROVALS INSPECTOR'S SIGNATURE DATE
SIGNED THIS .._._,-.DAY OF_ ......19_ ,- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT, ».__.._..__.: ._. __ BUILDING OR WORT(
ADDRESS g: ✓ SEPTIC TANK,SEEP.PIT(S)
�:-- ..1 ---- A. _._..._�____ AND/ORORAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL 0 DRYWELL 1
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE f
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED SIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE ,y�: a m SEEP.PIT(S)E] CESSPOOLS E]
OF PERMITTEE_ ,- .. .......
-�
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