HomeMy Public PortalAbout5601 A & B WELLAND AVE_Sewer__ CE EfiB;REV.6'78) I/'9
QPs APPLICATION FOR PERM IT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP MAP PR CES ED BY
V G
K
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BUILDING
ADDRESS
CONNECTION DATA
¢.LOCALITY
NEARESTSTATION DEPTH
CROSS ST. % i< ,' .'-.,'
UPPER
- MANHOLEREFERENCE LOWER
OWNER `� ✓,.r�,.f•9. -- .
TYPE OF CONNECTION LENGTH FROM
MAIL +/ y - _. Y. CURB P.L.
M.L.TO P.L.
ADDRESS a" Rte, A r.Y �%'�.✓ ++
76A642D � ��
CE 808 BEW 6/78; AP -ON FOF PEeRM IT
SEWE SEWAGE ISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP MAP t PROCESSED BY
BN 1 �� PG
BUILDING
ADDRESS ��7 G'r/� _sE�. `�Z' rL,Ji't� .��
LOCALITYC;:✓'", iZ.� �`',,G�-7� CONNECTION ATA
NEAREST / �."' ,,,! STATION DEPTH
CEASET. v• '�' UPPER
,..y MANHOLE REFERENCE LOWER
OWNER
TYPE OF CONNECTION LENGTH FROM
MAIL ,y"'�~ a Y. CURB P.L. M.L.TO P.L.
ADDRESS `S .: jam �✓�.Z,/,�;� ).
' ) P.G.NO. r
CO.IMP.NO. JOB NO,
CITY �f?,- ✓ iJ J.'r TEL.NO.
LEGAL �_y TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT <-
NO.OF SLOGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
4
INDUSTRIAL
CONTRACTORWASTE APPROVAL
ADDRESS CHARGES
CITY TEL.NO. CONNECTION CHARGE FEE
STATE LIC. REIMBURSEMENT FEE
LICENSE NO. CLASS
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE 0
u
J44OUSE SEWER CONNECTING TO
PUBLIC SEWER 0
NEW HOUSE SEWER
SEPTIC TANK,SEEPAGE PIT OR ���......
PITS AND/OR DRAINFIELD CONNECT
HOUSE SEWER CONNECTING TO BUILD
NG OR WORK ADDITIONAL
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG.OR SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINFIELD
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL Cl DRYWELL El
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❑
SEEP,PITIS)❑ CESSPOOLS J
OWNER'S Permit S
AUTHORIZATION TOTAL FEE VALIDATION
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
S IGNED THIS
OWNER OR
OWNERS AGENT �� "
ADDRESS
IHEREBY 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.
I HEREBY CERTIFY THAT I W PROPERLY. EGISTER AND/OR
LICENSED AS REQUIRED BY*OS ANGELS,�B'C LINTY A STATE OF
CALIFORNIA OR THAT I AM s E LEGAL ,W ER AlTEND TO RE-
SIDE IN,THE ABOVE DES KRENTIAL RTY.
SIGNATURE
OF PERMITTEE '