HomeMy Public PortalAbout5605 A & B WELLAND AVE_Sewer__ _Q;4
CE 'e(REV
' ,<I APPLI / TION 69P PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP BK 1./q PG 6,
MAP PROCESSED PROCESSED BY
BUILDING Y r P ��
ADDRESS- f9` _.._ G..L-:•��,f%�.���.»1✓ r."^ V F* ) 'r*"�...._- e-A CL_ _ .
LOCALITY /�. � CONNECTION DATA
NEAREST -9 STATION DEPTH
CROSS ST. '�/-`L'' �� T
UPPER
y ;1 MANHOLE REFERENCE LOWER
OWNERG.p. { 'f:R: >`'?� (:/�C -,. ✓..// .
TYPE OF CONNECTION LENGTH FROM
MAIL '`��� 7..,) Y. CURB P.L. M.L.TO P,L:
ADDRESS ? .�!�y, 6,. /AYf.{.T`j °�
P.C.NO
CO.IMP.NO. JOB NO.. l
CITY, ��..: TEL.NO. ` „7"" a-:?
LEGAL e, TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
r AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NaF DATE
BLOCK TRACT
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
'J�. ',,� INDUSTRIAL
CONTRACTOR �,°` f WASTE APPROVAL
ADDRESS CHARGES
CITY TEL.NO. CONNECTION CHARGE FEE
STATE LIC. REIMBURSEMENT FEE >"
LICENSE NO. CLASS 116
No. DESCRIPTION OF WORK FEEAPPROVALS DATE INSPECTOR'S SIGNATURE V
HOUSE SEWER CONNECTING TO '- In.
PUBLIC SEWER NEW HOUSE SEWER 0
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING 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
EXTN..0 ESSPOOL.DRYWELL.MANHOLE CESSPOOL [3 DRYWELL❑
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 I 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.
SIGNED THIS;y `�,,�;Z$%..g,yi*+;�"- 19.z;
OWNER OR �F--��
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 AJ�1 PROPERLY,f2F,G AND/OR
LICENSED AS REQUIRED B 'LOS ANG ELES.G1=17 AND TATE OF
CALIFORNIA OR THAT I A E LEGAL r R OFJAND INT D TO RE-
SIDE IN,THE ABOVE DE EO RE [�E IAL PRJJPEF!TY.
f .F
SIGNATURELjo
OF PERMITTEE p ��'� �` ^�?- '� .._..--•-
r
7eAaa2o "
CE 8013(REV.1,"8'-1,79 APPLICATION FOR PERMIT -
�JS '
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO. JGROUP I MAP PROCES5ED BY
BK PG [
BUILDING 7►^/ r3 .y�r,r 'a i;'. I` p'��,ll d.''1r -'
ADDRESS;_'�?�f' i. � .•.+^"' Limit-S x ' _.S ,('
LOCALITY ; `� CONNECTION DATA
NEAREST STATION DEPTH
CROSS ST.
UPPER
MANHOLE REFERENCE
OWNER '�G.-i.•L•�� / .�i.fJ -C"/��✓`� " f LOWER
TYPE OF CONNECTION LENGTH FROM
MAIL �,: Y. CURB P.L. M.L.TO P.L.
ADDRESS ✓ f„a f d = y.. yL..... P.C.NO.
GITYk. �,c.:, TEL NO.
CO.IMP,NO. JOB NO.
LEGALTRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
��}} AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT j, i ,3<
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT HWY.OR ST..WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
Tri INDUSTRIAL
CONTRACTOR i`:s„y' '""� WASTE APPROVAL
ADDRESS CHARGES.
CITY TEL.NO. CONNECTION CHARGE FEE
STATE LIC. REIMBURSEMENT FEE ®'
LICENSE NO. CLASS O
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR`S SIGNATURE u
HOUSE SEWER CONNECTING TO
PUBLIC SEWER r ! N
SEPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER I Fwd
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL id
HOUSE SEWER CONNECTING TO BUILDING OR WORK CA.
PRIVATE DISPOSAL SYSTEM 6f1
SEPTIC TANK,SEEP,PIT(S)
CONNECT ADDITIONAL BLDG.OR ANO/OR DRAINFIELD z
WORK TO HOUSE SEWER
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❑
SEEP.PITS)❑ CESSPOOLS
OWNER'S Permit $ ���
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.
SIGNEDTHIS ; t = D' F J:� .✓�"''"'} - i9-Cvr -
OWNER OR
OWNERS AGENT (..r -
ADDRESS �ip-`'�,S _ ,� fG'.. ✓ il�...'S',u �. �C;.. -_
1 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. d -
I HEREBY CERTIFY THA J,AM P PERLY STERED AND/0R
LICENSED AS REQUIRED LOS AEL OUNT ND STATE OF -
CALIFORNIA OR THAT I THE LEG V'O R OF,A INTEND TO RE- ..
SIDE IN,THE ABOVE 1 CRI
R $1q£NTI L P 1?ERTY,
SIGNATURE � -p
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