HomeMy Public PortalAbout9219-9219 1/2 WORKMAN AVE_Sewer__ 7CA642D
E-66-1 2-515 APPLICATION FOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Dep=trnent of County Engineer
County of Los Angeles BUILDING.-
WM.J. FOX,COUNTY ENGINEER ADDRESS-
CASSATT D.GRIFFIN, SUPT OF BUILDING LOCALITY ji
-—---------
FOR APPLICANT TO FILL IN If
e -
LEGAL
D LOT NO. OWNER
BLOCK TRACT -4MAIL
NO. OF BLDGS
ADDRESSv 7
SIZE OF LOT
NON ON LOT
L CITY TEL. NO.
USE OF
BUILDINGS d..
DISTRICT NO. GROUP MAP
SK PC
CONTRACTOR"
ADDRESS�� CONNECTION DATA
CITY
7EL� NO. STATION(
DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO. COUNTY
e, S
NO. DESCRIPTION OF WORK FEE
TYPE)DF-CJ*t ECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURD P.SEWER_ L. M.L. TO P.L.
_PUBLIC @ $ 3.5o
NOUS=' EVER CONNECTttdG 70
P IVATED�ISPOSAL SYSTEM 1.00
CONNECT ADDTT,6N4A-C KU". OR P. C, N0.
WORK TO HOUSE SEWER 1.00JOB NO,
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYST Eff. 1.00 TRUNK PERMIT NO, ROAD PERM IT NO,
DISCONNECT AND ABANDON SEWER STATE ENCPOACHMIENT
AND/OR DISPOSAL-SYSTE-M---- 1.00 __FERMIT NO.
SEPTIC TAN;,SEPACEPIT OR
PITS AND/OR DRAINFIELD -300 INDUSTRIAL
WASTE APPROVAL
CESSPOOL= DRYWELL
SPECIAL CONDITIONS ONLY 2.00
CHAPGES
CONNECTION CHARGE FEE
OWNER'S PERMIT d-, 00
AUTHORIZATION TOTAL FEE I I
REIMBURSEMENT FEE
I HAVE. THIS DATE CONTRACTED WITH THE IIEREIN NAM CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE_jjNSPECTOR'S SIGNATURE
.0 !ISE PUBLIC SEWER
SIGNED THIS- 2 DAY 0 19 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
'J. ____EUILDINGOR WORK
OWNERS AGENT
SEP-IC TANK,SEEP, PIT(S)
_AND/OR DRAIN.F-1-EL-D-------,,
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL DRYWELL O
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
IN TH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
ALTER, REPAIR,SEWER OR
PLUMBING AND SLIVERS. SEWAGE DISPOSAL SYSTEM
I HERESY CERTIFY THAT I AM PROPERLY REGISTERED AND/CR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT �-AM THE LEGAL OWNER OF THE ABOVE --ABANC�q�!-HOUSF SEWER
DESCRIBED RES I DENTLKt,'PRO PERTY. BACKFILL E--!7?-.
CESSPOOLS I
SIGNATURE
OF PERMITTEE
WILLIAM J. X.COUNTY ENGINEER VALIDATION R.A.WOOD,CHIEF PLBG. INSPECTOR