HomeMy WebLinkAbout0 (14) InEv.� CE BOB enei � -
CE APPLICATION FOR PERMIT
SEWER- SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO PILL IN [mEICrgD. clDBP MAP PROCESS!.EY
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wooaesaBUILDING
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LOCALITY ! i ! ` ,.(a 'CONNECTION DATA
NEAgBST ! �] STATION DEPTH
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MANHOLE REFERENCE VPPLR
OWNER L.��f./(J` SID
MAq. TYRE OF CONNECTION LENGTH FROM LOWER
} ADDRE55Y. CURB P.L. M.L.TO P.L
P.C.NO.
CO.IMP.NO. JOE NO.
CPT (.:. - TEL.NO.
LEO TRUNKPERM IT NO. ROAD PERMR NO.
D4ECRIPTION LOT NO. -
AFPIOAVIT WAIVER EASEMENT glCORD.INSTR.NO. DATE
!LOCK TRACT
NO.OF BLDGS.
SIZEOFLOT NOW ON LOT HWY.OR ST.WIO[NNG
USK OF
BUILDINGS STATE ENCROACNM[NT -
PlRMR NO.
• GONTRACTOP ,�1 ll, INDUSTRIAL
WASTE APPROVAL
ADORESE� GNAAGE!
'I CONNECTION CHARGE PEE k
C "TEL.NO. \E 0
STATE • LIC. • w(/ REIMBURSEMENT FE! V
LICENSE NO. CLASS 7
NO. 'DESCRI O WORK FEE APPROVALS DATE Ni►ECTOR'S SIGNATURE
1� NOOSE SEWER CONNECTING TO %' (L
PUBLIC SEWlR
SBPTIC TANK.SEEPAGE PIT OR N[W MOUSE SlWER cc
PITS ANO/OR ORAINFIELD
HOUSE SEWER CONNECTING TO BU LO NG OM WOpRAL 9
PRIVATE DISPOSAL SYSTEM - SK"IC TANK.SERF,PITIS I O
CONNECT ADDITIONAL SLOG.OR AND/OR 1'? DRAInIICLO 0.WORKTOHOUSISEWER
OVERFLOW SEEPAGE PIT.ORANFIELD CESSPOOL ORYWILL H
EKTN..GISSPOOL,ORYWELL.MANHOLE Q Q
ALTER,REPAIR OR ABANDON HOUSE JAAlPTIlT
LTER.REPAIR.9RW..OR
59 W!P OR DISPOSAL SY$T!M
SEWAGE DISPOSAL SYSTEM
ISCONNECT FLVG AND
ANDON NOOSE M.
. QOWNER'S Permit s JAUTHORIZATION TOTAL FEE >.� VALIDATION
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMEDTRACTOR TO CONNECT THE ABOVE DESCRISEO f N
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SIGNED THIS�/[_DAV O 7
OWNER OR
OWNERS AGENT -
ADORE 55
1 HERESY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AN STATE THAT THE ABOYE 15 CORRECT AND AGREE TO COMPLY
Wirth ALL COUNTY ORDINANCES AND STATE LAWS REGULATING -
f
PLVMBING
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR - .J�ly�. I r`•
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF -
i' CALIFORNIAORTNAT IAM THE LEGAL OWNER OF.AND INTENDTO RE-
I SIOEI..—%ABOVE OCBCRISEP RESIDENTIAL►gp/EMY,
�I
SIGNATOR! ZZ
OF PlRMTr �/v
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