HomeMy Public PortalAbout5548 WELLAND AVE_Sewer__ 76A642D
=E 808 fREV.6/78)
&MIT
op= APPLICATION FOR
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP MAP PF�OCSSED 8Y
ADORE BK PG
BUILDING
55 1'3 • Welland Av. �/ j� ,N �° - 'L-- ✓9
CONNECTION DATA
LOCALITY Temple City
-�J -
NEAREST STATION t'�' r / f_�• DEPTH ef
(CROSS S7. ')) ��`` 1 7
T Kuhn
MANHOLPRE�ERENCEf 'J , � UPPER R
OWNER 1J im Kuhn +. LA
�I _` TYPE OF CONNECTION LENGTH tt0.MAIL tr
ADDRESS } Santa Anita Y. � CURB P.L. M.L.TO .�. �
P
)�[(j�. ' f
CITY Arcadia TEL.NO. 4+}' doo CO.IMP.NO. OB NO. _
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO. - �
DESCRIPTION LOT NO.25
A
AFFIDAVIT WAIVER EASEMENT .INSTR.NO.RECORDDATE
BLOCK Ll TRACT l o8
NO.OF BLDGS.
SIZE OF LOT �7 NOW ON LOT HWY.OR ST.WIDENING
USE
BUILDINGS
Condo.NGS 1/ STATE ENCROACHMENT
T'� INDUSTRIAL
PERMIT NO.
.
CONTRACTOR re Deal Sewer Service
. WASTE APPROVAL
ADDRESS 2933 Ma.XSOn Rd,. CHARGES
CITYJA
31 Monte TEL.NO. 444-2020 CONNECTION CHARGE FEE
STATE LIC. �� REIMBURSEMENT FEE
LICENSE NO. 128 V� („
0 CLASS
NO. _DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTO. IGNATURE (�
HOUSE SEWER CONNECTING TO J
PUBLIC SEWER
SEPTIC TANK.SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR DRAINFIELD
CONNECT AL
HOUSE SEWER CONNECTING TO BUILD NG OR WORK
PRIVATE DISPOSAL SYSTEM
SEPTIC TANK,SEEP,PIT(S)
CONNECT ADDITIONAL BLDG.OR AND/OR DRAINFIELD
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL ❑ DRYWELL❑
EXTN..CESSPOOL,DRYWELL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR
SEWER ORD SPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑
OWNER'S
Permit $ SEEP.PITISI❑ CESSPOOLS
AUTHORIZATION f TOTAL FEE ; c VALIDATION
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_
OWNER OR
OWNERS AGENT
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF,AND INTEND TO RE-
SIDE IN,THE ABOVE DESCRIBED RESIDENTIAL ROP TY.
SIGNATURE
OF PERMITTEE
!llJJJ
76A642D
CE80t31REV.b/78l APPLLL6I 'k O lllN �- IWPE RM IT
Qs
SEWr=R - SEWA E DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY � '✓�
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP BK MAP P OC SED BY
ADDRESS �^I'� YY P�J..1 c,T�.t.i. lY�♦ r7.( l�'LL� +r✓i'
CONNECTION DATA
Locau7v rneRple -
NEAREST T� STATION {r � DEPTH 6CROSS ST. Dames Dr.
t) - - UPPER
MANHpL 'REF RENO '' OWER
OWNER i,j Zm nn TYPE OF CONNECTI LENGTH F OM �;a"'�
MAIL i 1.. CURB P.L. M.L.TO q
ADDRESS 1. I0 S• Santa Ani to � �' � P.C.NO.
CITY Arcadia TEL.NO. 446-7000 �CO.IMP.NO. ��.,✓-� JOB NO.
LEGALTRUNK PERMIT NO. ROAD PERMIT NO,
DESCRIPTION LOT NO-
2
//��Q AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
BLOCK A TRACT 1,�,7(,)
NO.OF SLOGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
CONTRACTOR ua.re Deal, Sewer Service WASTE APPROVAL
ADDRESS �/( !i ), ✓}((''�� //l� CHARGES
CITY El Monte TEL.NO. 444-'2020 CONNECTION CHARGE FEE
STATELIG. REIMBURSEMENT FEE
LICENSE NO. CLASS O
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTO 'S SIGNATURE V
HOUSE SEWER CONNECTING TO
PUBLIC SEWER _ NEW HOUSE SEWER
>SS'���,.
SEPTIC TANK,SEEPAGE PIT OR *4
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL W
HOUSE SEWER CONNECTING TO BUILDING OR WORK WWW
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG.OR SEPTIC TANK.SEEP,PIT(S)
WORK TO HOUSE SEWER AND/OR DRAINFIELD _
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL [IDRYWELL❑
EXTN.,CESSPOOL,DRYWELL.MANHOLE
ALTER.REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑
OWNER'S Permit $ "' SEEP,PIT(S)❑ CESSPOOLS
AUTHORIZATION TOTAL FEE ( VALIDATION
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_
OWNER OR
OWNERS AGENT
ADDRESS
I HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WrrH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSEDAS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF,AN INTEND TO RE-
SIDE IN,THE ABOVE DESCRIBED RESIDENTIAL PROP RTY.
SIGNATURE -� r!
OF PERMITTEE