HomeMy Public PortalAbout5603 WELLAND AVE_Sewer__ 76A642D
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J APP C.�tC; ION F IE RM IT
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SEWER- SEWAG DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP MAPj(( PROCESSED BY
PG
BUILDING t 7 r'� _. �,✓y ,+�-� V_
AD
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ADDRESS `. ,�, .-.sem,.;` ��T -
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LOCALITY CONNECTION DATA
a
NEAREST -�- -. STATION DEPTH
CROSS ST. _ - i
— — UPPER
r MANHOLE REFERENCE
LOWER
OWNER t--{" fi �iis.-.t. l.• ',.
TYPE OF CONNECTION LENGTH FROM
MAIL /'r"' r' Y. CURB P.L. M.L.TO P.L.
ADDRESS / TF�J, L i P C.NO. ^y
> d CO.IMP.NO. JOB NO. -
CITY +l '%C �" "� TEL.NO.
LEGAL t TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO. /
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
,. INDUSTRIAL
CONTRACTOR WASTE 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 (,
HOUSE SEWER CONNECTING TO r
PUBLIC SEWER
NEW HOUSE SEWER
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL T
HOUSE SEWER CONNECTING TO BUILDING OR WORK ��ii1111�4��
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG.OR SEPTIC TANK,SEEP,PIT(S)
WORK TO HOUSE SEWER AND/OR DRAINFIELD _
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL ❑ DRYWELL❑
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 S 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 .p¢y PAY QSF I9,tL
OWNER OR ff _
OWNERSAGENT ✓-/� �g .° t �''�`
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.
1 HEREBY CERTIFY THAT I PM PROP ERLGIS AND/OR
LICENSED AS REQUIRE D BY 1„OS ANGELES G UN- AND TATE OF
CALIFORNIA OR THAT 1 AM TME LEGAL OyyNNVVE O AND INT D TO RE-
SIDE IN,THE ABOVE DESC D RQSIOE'NTI PR PERTY."
SIGNATURE - --
`,R ✓,
OF PERMITTEE � �