HomeMy Public PortalAbout5547 WELLAND AVE_Sewer__ 76AG-20 APPLICATION FOR PERMIDISPOSAL
1
& -e�3:ESS SEWER-SEWAGE
DIVISION OF BUILDING AND SAFETY
Department of County Engineer MM�BUILDING —47
�. —_
County of Los Angeles ADDRESS IQ - _._�"`'--
JOHN A. LAMBIE, COUNTY ENGINEER C,Y c
CASSATT D. GRIFFIN. SUPT OF BUILDING LOCALITY
NEAREST
7BLOCK
R APPLICANT TO FILL IN —Wit✓- GWNER � !LOT NO. _ —.--- MAILTRACT_—�£�------ � - —. - !' � 71
LEGAL
{ y NO. OF BLDGS. CITY TEL. NO.
SIZE OF LOT �"� G'! NOW ON LOT - MAP
- ----- I GROUP
USE OF
DISTRICT NO. BK JG
BUILDINGS
--__-== = r-�
CONTRACTOIt��y j S��r`> + + -.__ --� CONNECTION DATA_
ADDRESS y��_ ?_ Y L r - STATION f IQ' 7 i „r _ DEPTH v CITY
TEL. N0. l L' MANHOLE REFERENCE /STATE.�REGISTRATION NO--Nq DESCRIPIION OF WORK FEE TYPE OF CTION LENGTH FROM_ _ P.L. M.L TOP L CUR HOUSE SEWER CONNECTING TO "?� -Y
' PUBLIC SEWER @
E .. -
SEPTIC TANK,SEEPAGE PIT OR $S.O - --�_ P. C. NO. - --
. �. PITS AND/OR DRAINFIELD _ - ^�I JOB N0.__ _..
OVERFLOW SEEPAGE PIT.DRAiNF1EL0 I CO. IMP, _-
--
EXTN (,E5SPOOL DAC PERMIT NORYWELL MAN.HOI E $2.00
_--- E ---- - ROAD
HOUSE SEWER CONNECTING TO TRUNK PERMIT N0. -- —
PRIVAIE DISPOSALSYSTEM -- ,-$--. --�-- - STATE ENCROACHMENT
_-
CONNECT ADDITIONAL BLDG.OR �.. i.00 I ;,+ PERMIT N0. ._-___---- ------- --'--
WORK TO HOUSE SEWER _ -°'-$_ -' -i-- --- ---_--
;NDUSTRIAL
I ALTER,REPAIR OR ABANDON HOUSE .A.
S,E_Vi ER OR DISPOSAL SYSTEM-_ _l_ S 10'I_.IL_-_.._-� -- WASTE APPROL CHAR
I _ _ CONNECTION CHARGE FEE _ .�...-.-�..
OWNERS PERMIT S — i -0_ REIMBURSEMENT FEE
AUTI�fORIZATION TOTAL FEE -=- 1 APPROVALS i DATE SPLCTG4'SSIGNATURE
---
-- —
I HAVE AT THIS CATS A CONTRACT WITH THE HEREIN NAMED CON- I
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING NEW HOUSE SEWER
I _
TO THE PUBLIC SEy�WER, CONECTADDITIONAL
1.S.o 19 DAY OF N
SIGNED THIS_—y� — BUILDING OR WORK._---- --_ -------
OWNER OR �.� ,f._ �,--�' SEPTIC TANK. SEEP,PIT(S)
OWNERS AGENT
-'�� AND%OR CRAINF,FLO __.-.---.1-_ ---- -_-
5 --
ADDRESS - —: - I --_ - -
-- - .-- - Cc55 PGOL G ------
I HEREBY ACKNOWLEDGE THAI' ! HAV.. READ THIS APPLICATION DRYl-- -- -
AND STATE THAT THE ABOVE S CORRECT AND AGREE F COMPLY - TE RE,PAIR,SEi OR I I
WITH ALL CO'J.NTY ORDINANCES AND STATE LAWS REGULATING SEWAGE DISPOSAL SYSTEM ------
PLUMBING AND SEWERS..
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
DISCONNECT--�-"�- -�
PLUG AND
HOUSE SEWER
ABANDON ._.. -- -----
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF _ _
CALIFORNIA
OR THAT 1 AM THE LEGAL OWN OFZTH, ABOVEBACKFILL SEPTIC TANKS L;DESCRIBE-D RESICENTIkL OPERTY. EEP. PIT S) t_) CESSPOOL>SIGNATURE ;.cr�OF PERMITTEE
PERMITTEE
VALIDATION ROBERT A. WOOD,CHIEF' HLBG. INSPECTOR
JOHN A. LA ✓ .COUNTY ENGINEER
a,a, CASH r
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