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HomeMy WebLinkAbout0 (15) 76A6@D CES081REV.6/781 e, APPLICATION FOR PERMIT SEWER-SEWAGE DISPOSAL COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN DISTRACT KD. I ORO➢r MArPG PROCESSED BY BK )) BUILDING ,7 )f .1` I'��� .,'. 1• LocALR 3/,.J %rJ CONNECTION DATA NEAREST •{' STATION `•DEPTH T. //, MANHOLE REFERENCE UPPER OWNER �� L'J/C,Cti/ST-,/ LOWER 4 TYPE OR CONNECTION l`•LlNGT'PROM ` MAIL r Y. CURB P.L. M.L.TO PlL I. ADDRESS �.� J;-(• ...• P.C.NO. \. CO.IMP.NO. JOE NO. 66AA _ TRUNK PERMIT NO. 1 ROAOPERMm DESCRIPTION LOT NO. AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO. DATE �. BLOCK TRACT NO.OF BIDGS. 4 SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING 1 UEEO STATE ENCROACHMENT OS PERMIT NO. CONTRACTOR OM INDUSTRIAL_, - �, WASTE APP .J WAST!APPROVAL ADDRESS 1�X / CHARGES CITY EL.NO..2 I(' CONNECTION CHARGE FEE STAT! LIG. RlIMBVRS[MENT PC! V STATE no. cuss C NO. DESCRIPthlON OF VVORK PE! APPROVALS DATE INSPECTOb'*A QNATURl tuJ HOUSE!EWER CONNlCTRVG TO Y. FUEL.SLWIR /' _ SEPTIC TANK.SEEPAGE PR OR _ NEW HOUEl SlW[R Y PRE AND/OR GRAINFIELD CONNECT AODITIONAL HOUSE SEW[RCONNSCTING TO BUILDING OR WORK PRIVATE DISPOSAL SYSTEM CONNECT ADDITIONAL BLDG.OR SEPTIC TANK.SEEP.►ml6) O ` WD RK TO'OUSE SOWER /Z) AND/OR GRAINFIELD i C OVERFLOWSIEPAOEPIT.DRAINPIELD CESSPOOL❑.DRYWELL❑ t `� EXTN..CESSPOOL.DRYWELL.MANHOLE ALTER,REPAIR OR ABANDON HOUSE ALTER.REPAIR.SEWER OR !l WOR OR D13PO3AL SYSTEM SEWAGE DISPOSAL SYSTEM DUCONNRCT FLUG ANO V ABANDON HOUSE SEWER BACKFILL SSFTIC TANKS❑ Permit ! SEEr.PRISI❑CESSPOOLS❑ OWNER'S VALIDATION AUTHORIZATION TOTAL FEE I HAVE AT THIS DATE A CONTRACT WRH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBEDFAISTING OWELLING TO THE PUBLIC SEW B• r+-•- - r 1 - SIGNEDTHISDAY '1. OWNEROR E OWNERS AGENT ti ADDRESS �. I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION •i'>^•�r AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMSING AND SEWERS. I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR LICENSED AS REQUIRED BY LOS ANGELES AND STATE OF CALIPORNIA OR THAT 1 AM THE LEGAL OWNER OF,ANO e..TO RE SIDE IN.THE AEOVSCRIBIO R SIDE NTIAL PRORlKEY. /w i.i TURE Of►ERMITTBE C r-- l . ___'. ice.• i r 1 l -- - 1- nT: li., lt.�; Cii it.