HomeMy WebLinkAbout1115A (5) �
76A6�4D
"°�'R`".°„a,,,'° APPLIGATION FOR PERMIT
��
SEWER- SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPUCANT TO FILL IN oisrni/c�r xo. c ur e� u�v p` PAOCESSE�BY
6UILDING� I / ✓ .� /' '
R�ORE55 U ��\ R�
O CONNECTIO ATA
LOCALRV '
NEAREST STATION .� s DEPTH �
GRO55 ST.
�J � UPrER
MANHOLEREFEAENCE �
WNE TYPEOFCONNECTION LENGTMFROM
�1�Il Y. CURB P.L M.LTOP.L
PDOAE55
P.C.NO.
CO.IMP.NO. JOB NO.
C TY TEL NO. Z �
o�L GRl TRUNKPERMRNO.' NOADPENMRNO. �
CFiPT10N LOTNO.
I.FFIOAVIT W0.1VER EPSFMENT REGORO.INSTR.NO. OI1TE
BLOGK TFACT � '
NO.OF BLOGS. '
SIZEOFLOT NOWONLOT HWY.ORST.WIDENING
USEOF STATEENCROACHMENT
BVILDINGS PERMIT NO. �
� INOUSTRIRL
CONTRl�CTOR WASTEI1GVROVAL
\
CHAR6F5
AOORE55
1 i a GONNECTIONCNARGEFEE �
CITY TEL.NO. O }
9TATE LIC. � REIM9URSEMENTFFE a'
LtCENSE NO.� CU55 � L O
NO. DESCRIPTION OF WORK Fee � APPROVAlS OATE IN E TOR'S SIGNATURE v ,
�
NDVSESEWEFCONNECTIN6T0 N O '
PUBLICSEWER (/D
SEFTIC TANK.SEEFAGE PIT OR NEW HOUSE SEWER �
PITS AND/ON DwAINF1ELO CONNECT AOOITIDNAL
HOUSE SEWERGONNEGTING TO OUILOIN6 OR WORK C.
GNN/TE�ISPOSMl5Y5TFM z '
GONNEGTADDITION,�LBIOG.OR AND/ORDRAINFIEIO�15)
WORNTONOVSESEWER
' OVEPFLOWSEEPAGEPIT.ORAIMFIELD CESSPOOI❑ DRYWELL❑ \ �_
- EMN.,CESSGOOL�HYWELLMMNHOLE �
ALTE R,RE V�IR OR 11BANDON HOtISE ALTE R.REPAIR.$E W ER OR ;
SEWER OR OISPOS/L SYSTEM SEWAGE�ISPOSAL SVSTEM
OISCONNECT PIUG ANO �
ABANOONMOUSESEWER
BACKFILL SEPTIG TI1NK5❑
Perm it s SEEP.PITISIO CESSPOOLS❑
OWNER'S VALIDATION
AUTHORIZATION TOTAL FEE O�
1 NAVE AT TMIS DATE A CONTRACT WRH TME HEREIN NANED GON- 1 �
TRAGTOR TO GONNECT TME 11BOVE OESCRIBED E%ISTING CWE4LING �� �'..t�.:A
TO TME PUBLIC SE WE
SIGNEDTHIS� DAYOF 19(�, � #�i�i i � �
OWNEROR r � ' '
' OWNERSAGEM �I f�h'�.H O G
AOORESS /�
1 NEREBY ACNNOWLEDGE TM�T I NAVE READ THIS/�PPLICATION ' ���1;� �O l:L
AND STATE THAT THE ABOVE IS CORRFCT AND AGREE TO COMVLY [' (�
P UMBINGAND ES W RS.INANCES ANO STATE LAWS REGVIATING O U� 9�V O
1 HEREBY CERTIFV THRT 1 AM PROPERLY RE6ISTEAED AND/OR
LICENSED AS REOUIRED 6Y LOS ANGELES COUNiY MNO STATE OF �
CIILIFORNIMORTMATIAMTMELEG�LOWNEROP.ANDINTENOTORE• � �
SIDEIN.THEAEOVEDESCRI6EORESI�ENTI11 PROPERTY.
SIGN�TVrtE ~ ' ' ' � .
OF GERMfTTEE
. _ . .. . . .... . I
, •l
N �
�
? W T'�'cZ O
% Z G�o o R,�r �y-
� �' -o '9 -a
. . n n ��� O m � �n
�
� . c `�'u+ ��Z � G
Q' O cf�' '<'y� a' `e�,++
� � �+ �O ��b r ti
r� � � 5 O'" Z`"� o
O � �N+ Q �'�-v'r. .mu'.Q� Z p
� p � . � �.�u,�' ,q� t�I� :�
� "� s t� '�` -Na n 2 Z � Y
` N 'K' � OT' U,c�`+ 2 O
O O' u�� . ..�y o �
' � Z" •'O O G� -o -n
�. � � � �Q � �
�+ S G v, -� C
A p� q
m u,� 3,
' �
a
_ �C,+
cn
�
. ,,l
�1 �; :
i .v ,
', ,, ✓`;� ,,I
%'"
`� -, , .�
i= _�, ,- � -,� �i' ` -
. . . ��f t.� � �: �.. t-v� � . �.'.
' V \i f t . (�.� �' �
� �
� � �•i l� �"' � vi � .,
1,1 � . v'�� �' /„ �'•� ''" �. ���� � .
�� �-' 1 � i' � �,
. . V;/L l``` t .. . �
v 4�,. �--' l�
1 '� i ,% t�-
� . ,, .`` F.i`., y �'�/ �'v y ;.` 4�:
� � �.. •� � ' •� r ,. ��. .
r. `` 'r, ..�/ l/ �. . I''. /, �� ` '`/ ('/ .
J .. ✓� �t� � �-' i.-.,��' �.'��
'. '. �.. � r�. ' ('� .,v f.` � � V. . �4�.
` /l ��� t. r, ✓ _ �`.,L/ - '
' .i vi r-� ,.`�%' `.. �,� � �--
�� -S ' r ����� .>� ��.� _
�- � � U
� ' �
�
', L
,
,
� �
�
,
, �,r
4