HomeMy Public PortalAbout5625 1/2 WELLAND AVE_Sewer__ s
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��8o�.a_I:e APPLICATION FOR PERMIT 1
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING y y.
ADDRESS `' . .-
JOHN At. LAMBIEW County Engineer
CASSAST D.GRIFFIN[,Supt of Building LOCALITY
FOR APPLICANT TO FILL IN doss ST:
LEGAL ✓
DESCRIPTION LOT NO. €, OWNER
BLOCK TRACTr T MAIL
n 8 a p ADDRESS y
77
NO.OF BLDGS. 1/
SIZE OF LOT NOW ON LOT CITY a t TEL,NO,
USE OF
CONTRACTOR 1 �' STRICT N0. GROUP -BK MAP P PROCESSED BY
BUILDINGS D' .
3l d4Y P
{
ADDRESS ;.x CONNECTION DATA
CITXAl
TEL.N0, aJ �_ STATION DEPTH
REGISTRATION NSTATE.Y MANHOLE REFERENCE UPPER
0, COUNT
R
NO, DESCRIPTION'aF W 4 FEE LOWER
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $8.00 1
SEPTIC TANK,SEEPAGE PIT OR TYPE.Or CONNECTION LENGTH FROM
PITS ANO/OR DRAINFIELD 0 $3.00 Y• ®_ CURB P.L. M.L�TO P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN-CESSPOOL,DRTWELL,MAN HOLE $2.40
HOUSE SEWER CONNECTING TO P,C.N0,
PR.WA_TE DISPOSAL SYS'T'EM @ $1.00 CO.IMP.NO. JOB No.
COND€ECT ADDITIONAL BLDG,OR r.
WORK TO HOUSE SEWER $I,OO '.- TRUNK PERMIT H0. ROAD PERMIT NO.
ALTER,REPAIR OR ABANDONHOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM $1.00 PERMIT'NO,
INDUSTRIALy .t.__
WASTE APPROVAL
CHARGES w
OWNER'S PERMIT $ < G CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE t REIMBURSEMENT FEE
— -
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'S SIGNATURE
.ACTOR TO CONNECT THE. ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER,
SIGNED THIS. DAY Qg 19— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL - P
OWNERS AGENT BUILDING OR WORK: a ...
ADDRES5 SEPTIC TANK,SEEP.PIT(S)
.�.__. AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL Q DRYWELL Q
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS, _SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/'OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISDISCONCONN HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL, OWNER OF THE ABOVE
DESCRIBED RESIDWTIAL PROPERTY BACKFILL SEPTIC TANKS
SIGNATURE
SEEP,PIT{S} CESSPOOLS[j
OF PERMIT TE
�t A "VAIMATION ROBERT A.WOOD
SUPERV1SINQ MECHANICAL ENGINEER
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