HomeMy Public PortalAbout9151 WOOLLEY ST_Sewer__ 76A 6420-CE808 A-7/76 '
APPLICATION FOR PERMIT
SEWER—SEWAGE DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP I SK MAP /]PS CESSED SY
BUILDING -1 tUj L10 y i•/L�
ADDRESS (lF!!�_�
LOCALITY L �.. - �.l j CONNECTION DATA
NEAREST STATION DEPTH
CROSS ST.
MANHOLE EFERENCE UPPER
/� LOWER
sTYPE OF CONNECTION LENGTH FROM
MAIL C, �e�.,; ,r (JA)0 L•� Y. CURB P.L. M.L.TO P.L.
A QORESS \ � '4 (V~�
.-� P.C.NO.
,W CO.IMP.NO. JOB NO.
CITY ry � L. NO. � �
LEGALCT NO. V /.y TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION (f iiI AFFIDAVITWMYu[� IRRD.INST .NO. i DATE
BLOCK TRACT 1 (/„/_
`♦' J� NO. OF SLOGS.
SIZE OF LOT66 x (/ NOW ON LOT HWY.OR ST.WIDENING
USE OF --
BUILDINGS . STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
CONTRACTOR _ — WASTE APPROVAL
ADDRESS ,.
CHARGES Q
// CONNECTION CHARGE FEE
CITY +TEL. NO.
STATE LIC REIMBURSEMENT FEE C
LICENSE NO. v CLASS _
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE W
HOUSE SEWER CONNECTING TO -- e„
PUBLIC SEWER (n
NEW HOUSE SEWER Z
SEPTIC TANK.SEEPAGE P17 OR -- _ "�
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL , i s
HOUSE SEWER CONNECTING TO BUILDING OR WORK 4`J �t
PRIVATE DISPOSAL SYSTEM SEPTIC TANK.SEEP.PIT(S)
CONNECT ADDITIONAL* 1- ,_ AND/OR DRAINFIELD
WORK TO HOUSE SEWER -
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL ❑ DRYWELL ❑
EXTN.,CESSPOOL.DRYWELL,MANHOI E @ --
ALTER,REPAIR OR ABANDON HOUSE ALTER,REPAIR,SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM I
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑
_ SEEPfCALIFORNIA
PITS) Cl CESSPOOLS ❑
OWNER'S Issuance Fee s
REBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AUTHORIZATION TOTAL FEE TATE THAT THE ABOVE IS rORRECT AND AGREE TO COMPLY
ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMEDBING AND SEWERS.
TRACTORTOCONNECT THE ABOVE DESCRIBED E%ISTING DWEEREBY CERTIFY THATI AM PROPERLY REGISTERED AND/OR
TOTHE PUBLIC SEWER. SED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF
SIGNED THIS DAY OF ) ORNIA OR THAT M THE LEGAL OWNER OF, AND INTEND TO
OWNER OR E IN, THE ABO ESC 1 ED ESIDENTIAL PROPERTY.
OWNERS AGENT TUREPERMITTEE
VALIDATION
CK. tv1.0. CASN
7CA642
3&F-6D 63 11�55 APPLICATION FOR PERMIT
DIVISION OF BUILDING AND SAFETY -SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
ADDRESS
JOHN A. LAMBIE, COUNTY ENGINEER
CASSATT D. GRIFFIN, SUPT OF BUILDiNG LOCALITY
FOR APPLICANT TO FILL IN NEAREST
LEGAL
DESCRIPTION, LOT NO OWNER
BLOCK TRACT MAIL
ADDRES�,
NO. OF BLDGS -NO
SIZE OF LOT CITY TEL-NOW ON LOT 7"�2 d
U SE OF
BUILDINGS _04�j
iz DISTRICT NO. GROUP BK MAP PG
CONTRACTOR
DATA
ADDRESS
___ AIION DEPTH
CITY TEL NO.
MANHOLE REFERENCE
❑ STATE
REGISTRATION NO, El COUNTY
NO, j DESCRIPTION OF WORK FEE
TYPE OF CONNECTION,,—., LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB tP.L M.L. TO P.L. 3 5
PUBLIC SEWER----,-- @ $3.50
__FSEPTIC TANK,SEEPAGE PIT OR
PITS AND OR DRAINFIELD (d>—$3.001
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. N0.
_EXTN.,CESSPOOL,DRYViELL,MAN HOLE Cq, $2_00 NO.-
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Qi $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER 0 $'_00 PERMIT NO.
I ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
ISEWER OWASTE
R DISPOSAL SYSTEM - APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ I 00
AUTHORIZATION TOTALFEE_ REIMBURSEMENT FEE
THE DATE INSPECTOR'SSIGNATURE
I HAVE AT THIS DATE A CONTRACT WITH L APPROVALS I
HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
10 THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS 4 DAY OF1 CONNECT ADDITIONAL
OWNER OR44 BUILDING OR WORK p t_
OWNERS AGEN SEPTIC TANK,SEEP'PIT(S)
AND/OR DRAIN F I I-I D L
O LEDGE THAT 1 HAVE READ THIS APPUCATfON CESSPOOL D DRY'WELLCj
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWER$, SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED As REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON E SEWER
DESCRIBED RESIDENTIAL PROPERTY, BACKFILL SEPTIC TANKS 1 0
SIGNATURE SEEP.PIT(S) D CESSPOOLS
OF PERM(TT
di
IOHN A. LAMBIE, COUNTY ENGINEER VALIDATION,.,--- ROBERT A. WOOD, C}HE F PLBG. INSPECTOR
CK. 8L C. CASH