HomeMy WebLinkAbout0 (14) 76A6@D
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S08 6/781
e, APPLICATION FOR PERMIT
SEWER-SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRACT KD. I DEaor MArPG PROCESSED BY
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BUILDING ,7 )f �`
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CONNECTION DATA
NEAREST •{' STATION `•DEPTH
T.
/, MANHOLE REFERENCE UPPER
OWNER �� L'J/C,Cti/S--J LOWER
4 TYPE OR CONNECTION l`•LlNOTH PROM
` MAIL r Y. CURB P.L. M.L.TO P.L.
I. ADDRESS �.� J;-(• ...• P.C.NO. \.
CO.IMP.NO. JOE NO.
66AA _ TRUNK PERMIT NO. 1 ROADPERMm
DESCRIPTION LOT NO.
APPIDAVIT 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 _I!•y �, INDUSTRIAL
M
((;; .J WAST!APPROVAL
ADDRESS
-'p J .."Gas
CITY EL.NO..�II'/- T CONNECTION CHARGE FEE
STAT! LIG, REIMBURSlMENTPRA
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uccnae no. cuss C
NO. DES[:RI ION Otu
F WORK PEC APPROVALS DATE INSPECTO�1'*4,QNATURE J
HOUSE!EWER CONNECTING TO Y.
PUBLIC SEWER j, _
SEPTIC TANK.SEEPAGE PR OR _ NEW HOUEl SlW[R Y
PRE AND/OR GRAINFIELD CONNECT AODITIONAL
NOUBE SEWERCONNSCTWG TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG.OR SEPTIC TANK.SEEP.►ml6) O
` WORK TO HOUSE SEWER AND/OR DRAINFIELD i C
OVERFLOW SEEPAGE PR.GRAINFIELD CESSPOOL❑.DRYWELL❑ t `�
EXTN..CESSPOOL.DRYWELL.MANHOLE
ALTER,REPAIR OR ABANDON HOUSE ALTER.REPAIR.5EW ER OR
!E WER OR D13P03AL SYSTEM 5lWAGE DISPOSAL SYST:M
DgCONNECT PLUG AND
V ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS Cl
Permit ! SEBP,PRlil❑CESSPOOLS❑
OWNER'S VALIDATION
AUTHORIZATION TOTAL FEE r,i r r,."!I
I HAVE AT THIS DATE A CONTRACT WRH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED M ! IMG
TO THE PUBLIC SEW B r+-•- -
SIGNEDTHIS �DAY OF r'
'1. OWNEROR
E OWNERS AGENT I'
ti
ADDRESS _�'w B,S..L L'
�. I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION •i'(• r •,•r L.
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY P -
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 ANGELESRCOUNTY AND STATE OF
CALIPORNIA OR THAT 1 AM THE LEGAL OWN! OF,ANO INjEND TO RE
SIDE IN.THE ABOV7E CRIBED R SIDENTIAL PRORlKIY.
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