HomeMy Public PortalAbout5139 DOREEN AVE_Sewer__ (2)TEMPLE CRTY
azDCR80APPLICATION FOR PERMITsaoee.ss
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION But LDInG
pg n
ADDRESS
CASBAT[AD.GRIFFIN, SuPl of Buildivq TLOCALITY177 IP C!
NEAREST
FOR APPLICANT TO FILL INcaoss sT
LEGAL l e Q/JC iJDESCRIPTIOWNER ON LOT NO.
MAILBLOCKTRACTiIX90ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY 7e TEL. NO.
USE OF
DISTRICT.NO. GROUP MAP PROC SED BYBUILDINGS
BK PG
CONTRACTOR CO[
ADDRESSy`m CONNECTION DATA
Cl:!]; TEL.N0. TION DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO. V ->d T COUNTY LOWER
No. DESCRIPTION OF WORK FEE
ABANDON
HOUSE SEWER CONNECTING TO
PUBLIC SEWER 04 TYP OF O CTION LENGTH FROM
SEPTIC TANK.SEEPAGE PIT OR P,L. M.L.TO P.L.
t PITS AND/OR GRAINFIELD
OVERFLOW SEEPAGE PIT,DRAINFIELD
E%TN..CESSPOOL.DRYWELL @S2.00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO. JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NOWORKTOHOUSESEWER@SI.00
SEWER OR DISPOSR
L SYSTEM
HOUSE
@ $1.00
STATE ENCROACHMENT
PER"'''
IN DUSTRWAST' R
CHARGES
OWNERS PERMIT 9— CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE Q REIMBURSEMENT FEE
1 HAVE AT THIS DATE AA,QQUIPTBR T WITH THE HEREIN IAMEO CON-
TRACTOR TO CONNECT THE ABOY ESCRIBEO E%ISTING DWELLING APPROVALS GATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW xousE ssweR
OWNER OR
i CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE P AT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL DRYWELL D
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER ORPLUMBINGANpSEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG ANDLICENSEDASREQUIREDBYLOSANGELESCOUNTYANDSTATEOFABANDONHOUSESEWERCALIFORNIAORTHATAMTHELEGALNEAOFTHEABOVE
DESCRIBED RESIDENT PROPERTY, BACKFILL SEPTIC TANKS
s SIGNATURE
SEEP.PIT(S) CESSPOOLS El
OF PERMITTE
ALIDATION ROBERT A. WOOD
CAaY.o. tl SUPERVISING MECHANICAL ENGINEER
LAD 5 4 4 6.2 1•1AY 3 1 1 1 D 2 5.0 0 ::