HomeMy Public PortalAbout5329 ZADELL AVE_Sewer__ 76A 6420 - CE808 - 9,'73 APPLICATION FOR PERMIT.' ,
COUNTY OF LOS ANGELES SEWER SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. P OWNER
- MAIL - -
BLOCK TRACT ADDRESS _
SIZE OF LOT NOW ON LOT CITY TEL. NO. -` ^ >.
USE OF _--
BUILDINGS DISTRICT NO. GROUP MAP PG PROCESSED BY
CONTRACTOR -`
ADDREs '- ;'� - t. .,. µ:'-:, CONNECTION DATA
CITY , 1,TEL ;A O. ` STATION *` DEPTH - -
STATEy„ *.. LIC ,UPPER
LICENSE NO: CLASS
MANHOLE REFERENCE
LOWER
�" +"
0. DESCRIPTI OF WORK BEE _ TYPE OF CONNECTION LENGTH FROM, .-
.� HOUSE SEWER CONNECTING TO Y. CURB P,L. M.L.TO P.L.
PUBLIC SEWER @ $7.00
SEPTIC TANK.SEEPAGE PIT OR P.C.NO,
PITS AND/OR DRAINFIELD $10.00 CO.IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM - @ $3.00 _ O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT W✓ it [AS EM[NT RECORD.INSTR.NO. DATE C>
WORK TO HOUSE SEWER @ $3.00 _ L.LI
OVERFLOW SEEPAGE PIT,DRAINFIELD _ �I
EXTN.,CESSPOOL.DRYWELL. @ $5.00
HWY.OR ST.WIDENING
ALTER,REPAIR OR ABANDON HOUSE -
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
MANHOLE@ $7.00 PERMIT NO.
-- — -
-- — INDUSTRIAL
� WASTE APPROVAL
O��/��R�S PERMIT s 3 00 CHARGES iW-
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAM ED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING —
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19`
OWNER OR NEW HOUSE SEWER
OWNERS AGENT —__ --
. r t .fir' CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
------ SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ---- ---
WITH ALL COUNTY OR AND STATE LAWS REGULATING
PLUMBING AND SEW ENS. CESSPOOL El [I
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICE NSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CA
,j_YF CRNIA OR,THAT I AM TO LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
DEI N. TJ;iE'ABOVE D ,,9 ,,IryB EO i�E51D ETAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE ,m+�'°' } ..f'>r BACKFILLSEPTIC TANKS
T ❑
OF PE4RMtTTEE - P-PIS) ❑ CESSPOOLS ❑
VALIDATION CK. M.O. CASH
r