HomeMy Public PortalAbout5543 WELLAND AVE_Sewer__ ;Z808
'6A6420 APPLICATION FOR PERMIT
4,7
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer DORES9 -I
WrLLIAM A. JENSEN, Sup't of Building LOCALITY - --------
�E—- -
N AREST
FOR APPLICANT TO FILL IN ICROSS ST. 4
LEGAL
DESC R"TfON LOT NO, Ow Aler e
MAIL
BI_Of;K TRG..0 r C, ADDRESS
NO. OF SLOGS.
SIZE OF LOT 0N LOT CITY TEL. NO.. q
- - - 2-7)��-71' NOW
U�L OF 11111 DISTRICT Nn.[3poup MAP
f 614(ell 1 1 e e,, 13K PG RROCE6SE'D BY
CONT RACTOR 7�
ACDRESSo
CONNECTION DATA
qyTEL.'N�-.)L STATION DEPTH
LIPPER
MANHOLE REFERENCE, -
-RATION NID, CO1
STATE Y
RECOWER—
G,151 jNT
Nc. DESCRIPTION OF IWORK FEE R CONNECTING TO TYPE OF CH ONNECTION LENGTFROM
1140USE.sm�'- Y.
CURB P L. M.L.TO P.L. L.
.
PUBLZC SEWER @ $5.00
0
StPT N SEEPAGE PIT OR j 0
-L.T) Co.IMP. NO a NO,
PITS DRAiNF(F !EI0.00
HOU5z SEWER ONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
4A1f DISPOSAL SYSTEM @ $3.00 0
AFFIDAVIT WAIVER FM�IIMII`4T RECORD. INSTR. O. DATE:
0.1 N C 1)0 1 CO)NA Iti
-
WoKIC P,:,4.j-k5 EWFIR @ $3.00
4--
0VLRI`!-0,-V SEEPAGE PIT,DRAINFIELD
EY >`+ C�ESSPOOIDRYWELL,MAN HOLE @ $5.00
NW Y.OR ST.WIDENING
Al"I E REPAIR OR ABANDON HOUSE
S
-- -Z DoSPOSAL SYSTEM @ S3,00 EIVEJR D? STATE- - ;ENCROACHMENT T
PERMIT NO.
INDUSTRIAL
'ANT.APP 29VAL
T
$
OVINE
S MIT 2 E,q.
� 00 CONNECTION CHARGE
AUTHORIZATION I ToTALF'E-E-- ----7
� ,-""L, ---- -
I HAVE AT THIS DATE A CONTRACT WITH HEREIN NAMED CON. REIMBURSEMENT FEE
ACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEVV&� APPROVALS DATE I INFPEC-IOR'S SIGNATURE
SIGNED THIs J e
way OF
- /*'e'vy
OWNER OR NEW HOUSE SEWER
- -- --- -------
OWNERS AGE
CONNECT ADDITIONAL
J,oy BUILDING OR-WORK
ADDRESS.-
S9PTIC TANK,SEEP,PIT 03)
I H FRF13Y ACKNOWLEKDaE THAT I �AVE READ THIS APPLICATION AN11/.R LR(AINFIELD
AND STATF THT THE A�OVE 1%r, CO RRLC1 AND AGREF TO COMPLY
WITHALL
E:ALL COUNIY ORDINANCES AND STATLAWS REGULATING
PLU MH INC, AND SEWERS. CESSPOOL L7 DRYWELL ❑
CERTI
I HEREBY AS
F THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.,SEWER OR
LICENSED REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL-SYSTEM
C"AFORNIA 011 THAT 1TH : AN,T.,HE LE SAL OWNER gF 4A . IT11"11
RESIDE 1'. PER NO TO 76-co"Ec�-PLU-G -A-N-D-,--
E :e- ABANDON SH 0 LIFE SEWER
�Z�1)1 T I A
S?CNATURE SACKFfLI-SEPTIC TANKS
- CESSPOOLS
- ----- v SEEP,PIT(S) L1 LSI
--VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
M.O. CASH