HomeMy Public PortalAbout5527 WELLAND AVE_Sewer__ E 8(7:'3.152
6A6420 APPLICATION FOR PERMIT
COUNTY OP61-OS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER - -----
BUILDING AND SAFETY DIVISION BUILDING
I L"'N G
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
COLEMAN W. JENKINS, SUPT. OF BUILDING
LOCALITY
F'NEAREST
Or
FOR APPLICANT TO FILL IN CROSS-ST. e
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT
ADDRESS
NO. OF BLD GS.
SIZE OF LOT NOW ONNO.
LOT CITY TEL.
USE F DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS d; d
BK PG
CONTRACTOR
PRO�:E
ADDRESS CONNECTION DATA
CITY TEL- NO. STATION DEPTH
STATE LIC
LICENSE NO, CLASS MANHOLE REFERENCE OWER
NO--- DESCRIPTION OF WORK FEE CONNECTION LFNGTH*ROM
?I _J
-�;--SSEWER-- CONNECTING T& CURB P 1: WL.TO P.L. CL
HOUSE $5.00 Y.
L.PUBLIC SEWER
_------------- -i--— " . P,C.NO. 0
i SEPTIC TANK SEEPAGE PIT OR I CO. IMP. NO. JOB NO.
PITS AND/Of��RAINFIELD _ ... @ $10,00L --t-- _ - ___—
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO,
PRIVATE DISPOSAL SYSTEM @ $3.00
u
CONNECT ADDITIONAL BLDG.OR —�DAVIT7 WA ;!M ��5RO IWSTk NO. DATE
WORK
TO HOUSE SEWER @ $3.00
OVERFLOW PAGE Pir.DRAINFIEUD
FXTN..CESSPOOL.DRYWELL.MANHOLE 0 $5.00
HWY.OR ST.WIDENING
ALTER.-REPATR 61RABANDON]HO USE— z
SEWER OR DISPOSAL SYSTEM $3.00— -STATE ENCROACHMENT
PERMIT No,
INDUSTRIAL
WASTE APPROVAL
______CHARGES
OWNER'S PERM 2' 00
CONNECTION CHARGE FEE
AUTHORIZATION
TOTAL FEE
IHAV E AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19,
OWNER ORNEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADORES S
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINVIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING
CESSPOOL El DRYWELL Cl
PLU NG AND SEWERS.
RS.
� HEREBY
CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS NREQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWER OF. AND INTEND TO —DISCONNECT PLUG AND
RESIDE IN,
THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE LSE
PTI CTANKS
OF FIF�RIVITTTEt
SFEP.PITIS� ❑ CESSPOOLS ❑
VALIDATION JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
CK. M.O. (;ASH
7 4 4 6 N 2 7
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