HomeMy Public PortalAbout9148 WOOLLEY ST_Sewer__ '6A6642070 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ,. d'�
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS , f 'd' Y' Cs
COLEMAN W. JENKINS, SUPf
T. OF BUILDING Mme` rnr �� tt
LOCALITY +-' .
NEAREST
FOR APPLICANT TO FILL 1N CROSsT--- / C-_y �) ✓ _
(PRINT OR TYPE ONLY) _ - ----
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DESCRIPTION LOT NOJ — —^--- OWNER
BLOCK TRACT _ ADDRESS 3 _'-T 2 C�
NO. OF BL GS.
I— = p
-SIZE OF LOT NOW ON LOT CITY .� v :t, I F=LC4O.
USE OF---
BUILDINGS
F —BUILDiNG5 D1S1RICT NO. GROUP CLASS NtAP PR.'.Y�CESSED BY
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CONTRACTOR � ,L_L F''. -Yr•". -- —___ J '>� �- �' 1 d. 6' 8v ",,'€t.i'✓ '"ear
ADDRESS - d Ea 7� CONNECTION DATA
CITY �� �y� � Ilkr [ STATfON ���!r-`-�- DEPTHy-�:;,ia'
✓r PT'_4, 'G4Lc, !G e'1�' TE L. NO—.�.--i ,7 P 'G —_-.�=wry
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STATE yi' '. LIC j�`` �"^'" MANMANHOLEREFERENCE, ,+ ,r
LIc E'NSE NO:. 1r {,✓ G1..A55 C _'Y _ r ,sP /'gr_� LOWER
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.DESCRIPTION OF WORK FEE_ TYPE OF CONNECTION LENGTH FROM ,y
HOUSE SEWER CONNECTING TO — Y. CURB —P.L.} M.L.70 P.L.
PUBLfC SEWER _ 55.00_ '-;S'L•' _ P C NO -- —
SEPTIC TANK SEEPAGE PIT OR "�'
.PITS AND/OR DRAINFIELD 550..00 CO,IMPNO_ �° F. __- JOB NO.
HOUSE SEW ER.CONNEC7ING TO
TRUNK PERMIT NO. ROAD PERMIT NO. fan
'
PRIVATE DISPOSAL SYSTEM $3.00
-AFFIDAVIT
AFFIDAV17 I WAIVER�—EASCMeNT�RfCORO INSTR.NO. I DATE
WORK TO HOUSE SEWER as 3.0o
EXTN.,C ESSPOOL.DRYW EL L.MANHOL.E $5.00 HWY.OR S7'.WIDENING
ALTER,REPAIR OR ABA NOON HOUSE �_- - — -
—_. SEWER OR DISPOSAL SYSTEM _� 53-00 STATE ENCROACHMENT �!
PERMITNO. 11.1
INDUSTRIAL
WASTE APPROVAL
_t--` —0 . --_4 CHARGES
OWNERS PERMIT-- -
— 0--5` 2 --- -- —
;,y CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE _ ------ ----- -------
I HAVE AT THIS MEF
DATE A CONTRACT WITH THE HEREIN NAMED CON. REIBURSMENT EE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ---- — -- ------
TO THE PUBLIC SEWER. APPROVALS ATE IN ECTOR F SIGNATURE.
SIGNED THIS__ DAY OF —19A "----- — "�----
li OWNER,OR NEW HOUSE SEWERS
OWNERS AGENT _ _--' ---- '—
CONNECT ADDITIONAL
BUILDING OR WORK
SEPT IC 7AIV K.SEEP.PITS)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STA TE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUM BING AND SEWF_RS. CESSPOOL ❑ DRYWELL C
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR.SEWER OR
LICENSED AS RF,OUIRED BY L.
ANGLES COUNTY AND STATE OF SEWAGE D15POSAL SYSTEM i
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO pISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED? IOENT�AL PROPERTY, ABANDON.HOUSE SEWED. r't
SIGNATURE BACKFILL 5EPTIC TANKS +j
OF PERMITTEE �" T '4�,rY^`�1 y^� ❑�
SEEP.PIT tS) � CESSPOOLS
VA ATION JACK]R. ALLEN
SUPERVISING MECHANICAL ENGINEER
M.0, CASH
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