HomeMy WebLinkAbout0 (22) ' 76A641D - -
"B08'R`Y6,78i APPLICATIONfFOR PERMIT-
a'. SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
i• DBTRICTNO. GWF - - PROCESSED BY
� FOR APPLICANT TO FILL IN , BK MAP PG -
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CONNECTION DATA
LOCALRY
NEAREST STATION DEPTH
GROSS ST. {.� ��'
) y UPPER
M WNER �t/1/J (-LG�(�•(1I� R. MANHOLE REFERENCE
OIOWIR
TYPE OF CONNECTION LENGTH FROM
IMAIL
AGGRESS {( r• Y. CURB P.'L. M.ML-TO►.L.s"i`
I
CRY •_I� ✓1//'•, TEL NO. CO.IMP.NO. JOB NO.
LED TRUNKPERMRNO. ROADPERMRNO.
ORSCRIIRIO LOT NO.
AFFIDAVIT I WAIVER I EASENEIT RECORD.INSTR,NO. DATE
BLOCK TRACT
NO,OF SLOGS. ,
P SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
ue OFDI
BUSK. NGB STATE ENCROACHMENT
�+�• P[RMR NO.
..h r . �-
INDUST RML.
CONTRACTOR 4 T WASTE APPROVAL
ADORE9 '1� CHARGES
CONNECTION
CRY 'J • [L NO. N '�'iJ r��1/ CONNCCTION CHARGE PEE R
STATCI Y ••' ' .LIC. gE1MBVRSEMFNT FlF O
LICENSE NO. 1 CLASS' V
NO. DESCRIPTION LLI
OF WORK REE ,C
APPROVALS DATE INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO 11.
PUBLIC SEWER NAW HOUSE SEWER
SEPTIC TANK.SElPAGE 11 11 ad
PITS AND/OR GRAINFIELD CONNECT ADORIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM SEPTIC
CAL BTANK.SEEP,PITISI O
CONNECT ADDITIONAL / AND/ DRAINFIELD
J WORK C HOUSE SNS
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL❑ DRYWELLQ H
E%TN..CESSPOOL ORYWELL.MANHOLE
ALTER,REPAIR OR ABANDON NOOSE
p SEWER OR DISPOSAL SYSTEM ALTER,RCPAIR,SEWER OR
SEWAGE DISPOSALSYST{M
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTICTANKS Q _
fOWNER'S Permit { BEEP.PITISI❑CESSPOOLS❑
.AUTHORIZATION I TOTAL FEE VALIDATION
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON, I C
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING •II n
i TOTNE PUBLIC SEWER -y 1,
SIGNED THIS. �DA,OF -'T ' lsl,� �di Y•�I�:--
iOWNER OR _
ADDRESS
1 HEREBY ACKNOWLEDGE THAT I HAVE"MAD THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT ANO AGREE TO COMPLY
PWITH ALL
LUMBING AND.TV ORDINANCES AND STATE LAWS REGULATINGSEW
.I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR
LICENSED AS REQUIRED BY LDS ANGELES COUNTY AND STATE OF
I CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF.AND INTEND TO RE-
i SIDE IN.THE ABOVE DESCRIBED RESIDINLA%,PNO►EMY.
I'
..NATURE
Of PIRMITTElIf
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