HomeMy Public PortalAbout4922 WILLMONTE AVE_Sewer__ 1
=608 t i-57 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 4022 11 LLrCJnte
IOHN A, LAMBIL County Engineer ADDRESS
CASSATT D. GRIFFIN, Sup't of Building LOCALITY Temple psi t y
NEAREST'
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL d
.�3 - f% _ 2 �Veb r ":ons Uructe;,�.�.�n �✓�
DESCRIPTION LOT ND: OWNER +
MAIL 27
BLOCK TRACT its ADDRE S ` San Gabriel Blvd..
NO.OF BLDGS. tan. iaiunei.
SIZE OF LOT NOW ON LOT CITY TEL.NO.
USE OF .c'S.ezosideace
BUILDINGS a FIST . GROUP MAP
BK PG
CONTRACTOR L.D• � CoADDRrt��ESS BOx 203 CONNECTION DATA
CIT,s cawi Pear TELN0. E,,d . 3 � DEPTH
'i t, STATE MANHOLE REFERENCE Ug.C�it
REGISTRATION NO. J- ,/ COUNTY
NO. i DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO U U
PUBLIC SEWER (0 $3.5q � L. M.L.TO P.I_
TYPE OF CONNECTION,--- LENGTH FROM _
SEPTIC TANK,SEEPAGE PIT OR Y. CURER tp.
PITS AND/OR DRAINFIELD $3,00
OVERFLOW SEEPAGE PIT.DRA.INF1ELD �-
EXTN„CESSPOOL,DRYWELL,MAN HOLE @ $2,00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1..00 /%)'
l%' P.C.N.
_ CO,IMP.NO. J `::, JOB N`0.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK.PERMIT 140, ROAD PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE — - -
SEWER OR 1+SPOSAL.SYSTEM $1.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT S 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE.
I HAVE AT THIS DATE A CONTRACT WITH 'THE HEREIN NAMED CON. i
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE [INSPECTOR'S[INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS y�-DAY OF—_ i 9_, NEW HOUSE SEWER
OWNER OR Yew CONNECT ADDITIONAL
OWNERS AGENT _BUILDING OR WORK
.ADDRESS - - SEPTIC TANK,ST
:SEEP, PIS)
—_------ -- --- AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE' THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE A13OVE IS CORRECT AND AGREE TO COMPLY _CESSPOOL[] DRYWELL[I
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS, ALTER,REPAIR.SEWER OR�
-
L HEREBY CERTIFY THATSEWAGE DISPOSA4.SYSTEM
1 RM PROPERLY REGISTERED AND/OR - -
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RES DEN.TTAL PROPERTY BACKFILL SEPTIC TANKS [I
SIGNATURE w SEEP.P[T(S) [I CESSPOOLS Q
OF PERMITTEE
�P VALIDATION ROBERT A. WOOD
C M.O. CASH SUPERVISING MECHANICAL,ENGINEER