HomeMy Public PortalAbout5217 WILLMONTE AVE_Sewer__ FOA642D
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-57 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
,,W AbLANZIE, County Engin!nr
ADDRESS
TT D. GRIFFIN, Supt of Building
LOCALITY z"
ir
FOR APPLICANT TO FILL IN NEARESTc
LEGAL
DESCRIPTION LOT NO* _OWNER.-_,
BLOCK TRACT MAIL
NO,OF BLDGS.
41ZE OF LOT NOW ONLOT
2L71�� CITY TEL.N0.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP
K G
ADDRESS P
CONTRACTOR 4.5
CONNECTION DATA
Z J-'
CITY r TEL,NO. STATION / DEPTH
' ell
7
NO.
MANHOLE REFERENCE UPPER;
)
REGISTRATION 1,Y A�
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3-.
SEPTIC TANK.SEEPAGE PIT OR TYPE OF Olt TION LENGTH FROM
PMAND/OR DRAINFIELD $3.00 Y• 'CURB
P.L. M,L.To P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL.D-RYWELI.,MANHOLE q $2,00
F—HOUSE SEWER CONNECTING TO P.C NO,
11 PRIVATE DISPOSAL SYSTEM )Mi$1.00 CO.IMP.NO. JOB No.
CONNECT DITIONNAL DL�G.OR
iOR T, TRUNK PERMIT NO, ROAD PERMIT NO.
,I,OR A
ALTER,FWAIR OR XE&YAD.N HOUSE
STEM
SEWER OR DISPOSAL STEM $1.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
—
WASTE APPROVAL
CHARGES
OVVNER'S PERMIT $ 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE I
.I , /,)
- RETME'URSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE iINSPECTOR'S SIGNATURE
TO THE PUBLIC SEER.
S i G N E D THIS 9AY, 19 LY _j.EWHOUSE_SEWER
OWNER OR
CONNECT ADDITIONAL
OWNERS AGENT IL LUILDING OR WORK
SEPTIC TANK,SEEP,PiS)
ADDRESS---:S T(AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 13 CORRECT AND AGREE TO COMPLY CESSPOOL Ej DRYWELL D
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
�EWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY--T-tiAT I,.AM P OPE RLY REGISTER. AND/ __!�
LICENSED AS REQUIRE, ByAqS �'111 LES 11URINTY A STATE,()F DISCONNECT PLUG AND
CALIFORNIA OR'THAT &_Q T ABANDON
'PF!!yr.LE9A,L 0.#NER 0 TJIE ABOVE DON HOUSE SEWER
DESCRIBED RESIDENTIA BACKFILL SEPTIC TANKS El
IGNATURE SEEP. PIT(S) El CESSPOOLS
OF PERMfTTE
ATION F.ODERT A. WOOD
CK. m 0, CASH SLIFERVISING MECHANICAL ENGINEER
1 4 2 15r�'; JAN 0 A 6 0 0