HomeMy Public PortalAbout9124 WOOLLEY ST_Sewer__ 76AE APPLICA`T`ION. FOR PERMIT"
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E•-65663 52•Sd
DIVISION OF BUILDING ARID SAFETY SEWER-SEWAGE DISPOSAL
Dep=artment of County Engineer
County of Los Angeles B U I LDt N G,
WM..J. FOX, COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN,SUPT of BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL
—LES CRI PIQTW LOT NO, 4. �, � OWNER:,.
BLCC'K _ TRACT * � hiAIL -
� ��.
N0. ON OF BLDGS.
LOT
51XE OF -- NOW LOT CITY (}
f - TEL. N , �.
USE O F LOT ON
BUILDINGS w` _ DISTRICT NO, GROUP I MAP
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"CONTRACTOR
ADDRESS CONNECTION DATA
C1TYL � 4 �c1eL. NQ.. I,� STATION � F �' e ". d1' DEPTH -
®-9TATL MANHOLE REFERENCE
REGISTRATION NO, + � i ❑ COUNTY —>< -,-.I i=J r' UPPER _ .L4yh-E-R_
—"-3'"" Tk'PE 6F CONNEC 1�y+i ., LEhGT.H FROM .
NO. DESCRIPTION OF WQRK FEE Y, CURB _P.L._ M,L TO P.L_
or HOUSE SEWER CONNECTING TO
PUBLIC S ,k ER
JI HOUSE SEWER CONNECTING TO ��---
PRIVATE DISPOSAL SYSTEM 1.00 --i.
---
CONNECT ADDITIONAL BLUE. OR - ---- �-- N0
-`—'--
W'UR_KT_0 HOUSE_SEW E_R_ 1.00 _ CO,TMP. . � � 1 JOB, NO.
Vi ALTER_OR REPAIR EXISTING
S� VER OR DISPOSAL SYSTEM 1,00 TRUNK.PERMIT NO. ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER — ."—_-. --_ -_........_....______._..._..
AND/OR DISPO_S DISPOSAL SYSiEM _ 1.00 I - 5�'AT�'ENCROACHMENT ^'
SEPT.^.TANK SEEPAGE PIT OR
PERMIT NO•
PIIS dNU�OR DRAIN IEI.D 2.00 I INDUSTRIAL
CF�SPOOL DDPAI IF ___ WASTE APPROVAL
5$C IAL 40S`DI 1i ONS ONLY 2.00 —' -
CONNECTION CHARGE FEE
0vMERpEfiPfilTT _z OU _
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN N.AMiD CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EX!STING DhELLING APPROVALS DATE INSPECTOR'SSiCNAiURE
TO THE PUBLIC SEWER -
�' NEW.LOUSE SEWER
SIGNED THIS----- DAY
,QF
"CONNECT ADDITIONAL
OWNER OR ;` f5 BUILDING OR WORK
OWNERS A G E N• .,„"
SEPTIC T.b,NK SEEP,PIT(5)
ADDRESS_ AND/OR DRAKNFIELD
I HEREBY ACYNOWLLADGE 1"HAT I HAVE READS APPLICATION CESSPOOL[] DRYwELL 0
AND STATE THAT THE ABOVE IS CORRECT AND d�, TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS.
SEWAGE DISPOSAL SYSTEM� _
1 HEREBY CREOU Y THAT 1 AM PROPERLY LY ' NTY REGISTERED ATE OF DISCONNECT PLUG AND
_
LICENSED AS RcI;�UIREDBY LOS ANGELES CO�IIN7Y AND STATE OF
AL OWNER OF THE ABOVE ABANDON HOUSE SEWER _
^r _ „> -1 BACKFILL SEPTIC TANK$0
CESSPOOLS LJ
DES�RkBEO RESJD'cNT.iAL, CPERTY - $BEP.P1T(51 ❑
CALIFO 'A 04 THAT i A:41 THE LEG g#
SIGNATURE
OF PER14ITTEP___
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
7.7
BY BY ".
DEPUTY DEPUTY
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BY BY -
�w� DEPUTY DEPUTY