HomeMy Public PortalAbout9828 WOODRUFF AVE_Sewer__ 76A 642EC B.B-7'/T6
APPLICATION FOR PIT
- t u e PERMIT
SEWER—SEWAGE DISPOSAL
DISTRI:C'TU0. GROUP. MAP PROCE.99ED BY
FOR APPLICANT TO FILL. IN _BK P,
BU.1 DIN h. `toc/ I C
ADDRESStjtVe 6
,j CONRTECTION
LOCALITY .DATA
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NEAREST � STATION DEPTH
-�¢ � R
GROSS'ST. 'RL M UPPER
MANHOLEEFERENCE C"6z .�.y r
/ I L R
OWNER ! / TYPE Or.0 CTION LENGTH FROM
MAIL Y:: CURB P.L. _ M.L.TO P.L.
ADDRESS~ . ".i �, ,I .} P,C.NO.:
CITY .,. / TSI. NU.,, CO.IMP..NO. ia JOB NO.
DESCRIPTION LOT NO. y P�r ,A 'TRUNK PERMIT'WO.. ROAD PERMIT NO..
,AFFIDAVIT WAIYER [AS[N[NT RECORD,INSTR.NO.. DATE
BLOCK TRACT_
.. _ _ ..
NO'. OF BLDOS. -
SIZE. OF LOT NOW,ONLOT � 'HWY.:OR ST.WIDENING
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USE OF '.
BUILDINGS � {. STA.TE ENCROACHMENT
�
. _ PERMIT N.O. ^'
CONTRACTOR �' + •'� l� INDUSTRIAL '-
It WASTE APPROVAL
ADDRESS, CHARGES
CP(S .�"_(,... TEL. NO. CO'N'NECTION CHARGE FEE.".20 '
STATELIC '.REIMBURSEMENT FEE
LICENSE NO. n � / CLASS - �.NO. DESCRIPTION OF WORK FEE APPROVALS
_ DATE INSPECTOR'S SIGNATURE.;
HOUSE SEWER'CONNECTING TO
PUBLIC SEWER _
SEPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/.OR DRAIN FI ELO CONNECT ADDITIONAL �j�]ryK r. v r a X
HOUSE SEWER CONNECTING TO BUILDING OR'WORK
PRIVATE DISPOSAL:'SYSTEM
SEPTIC, PIT'18�I
CONNECT ADDITIONAL BLDG:OR p_ AND/OR
-
WORK TO HOUSE SEWER AND/'OR DRAjNF1ELD
OVERFLOW SEEPAGE PIT:DRAINFIELD.. CESSPOOL Q DRYWEL'L ❑
EXTN..CESSPOOL.DRYWELL,MANHOLE
-
ALTER.REPAIR OR ABANDON HOUSE ';1 ALTER,REPAIR,SEWER OR
:SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL.SYSTEM _
a DISCONNECT PLUG AND
- ABANDON HOUSE SEWER ,
BACKFILL SE TANKS ❑
SEEP.PIT I5).P.❑ 'CESSPOOLS ❑
OVf�11TER'S' Issuance F'ee S t7 v
EREBY AOKNOWLEDGE THAT 1 HAVE READ' THIS. APPLICATION
AUTHORIZATION TOTAL FEE aN..o STATE TFIAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCE'S AND STATE LAWS REGULATING
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON, pLU'MBING AND'SEWERS.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING -
TO THE PUBLIC SEWER, - 1 HEREBY CERTIFY THAT I AM PROPS EGISTERED ANDJOR
l
':LICENSED A'$ REQUIRED BY LOS ANLL COU TY AND STATE OF
SIGNED THIS DAY OF r��1 ;.CA'LIFORNI'A OR THAT I AM THE LEGAL OWNER F. AND INTEND TO
OWNER OR J ,. rE51DE IN. THE AB VE. DESCRIBED R SIDENTI PROPERTY.
• OWNERS AGBN.:
Slt iIATORE
ADDRESS OF PERMITTEE.. 6h ��CGG
- - o%.CATION
CK', l M.O. CASH