HomeMy WebLinkAbout1692A (10) II 76AM2D � �
� CE808(REV.6/78)1/79 APPLICATION FOR PERMIT
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SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAPETY
FOR APPLICANT T FILL IN D157NICi NO. GROUP MAP PROCESSED BY
BK PG
BUILOING � r3 ��- /G
AODRESS
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E �ocn�rtv - — — -
NEAREST - --'"-'- -' - - --- -- -. - STATION ._ . f /S DEPTH �
CROSS ST. � '� . . .
� UPP
MAN E F GE � R
OWNER
_ YP OF ONNEGTION � LEN6TH FROM
M'1`�L - • Y. GURB M.LTOP.L
ADDRE55
P.C.NO. �
CO.IMP.NO. JOB NO. -
GITY TEL NO.
LEGAL TRUNK PERMR NO. ROAD PERMIT NO.
❑ESCRIPTION LOTNO.
� AFFIDAVIT WAIVtR EASEMENT RECORD.INSTR.NO. DATE
9LOCK TRACT '
. NO,OF BLDGS.
512E OF Lo7 NOW ON LOT ' HWY.OR 5T.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
GONTFiAC7oR INDUSTRIAL
WASTE APPROYAL
i ADDRESS Q CHARGES
� CRV TELNO. � CONNEGTIONCHARGEFEE �
4 STATE LIG. REIMBURSEMENTFEE
I LIGENSE NO. GLA55 �
�
� NO. ❑ESCRIPTION OF WORK FEE APPROVALS O E � 5 GTOR'SSIGNAT R� V
HOUSE SEWER GONNEGT�NG TO �q
) PUBIIC SHWFR �v
SEPTICTANK.SEEPAGEPITOR . NEWMOUSESEWER �
P1T5 qn0/OR bRAtNF1EL� CONNEGT ADDRIONAL ltJ
HOUSE SEWEq CONNECTING TO BUIIDING OR WORK G.
PRIVATE OISPOSALSYSTEM lA
CONNECTAODRIONA�BLDG.OR SEPTIG TANK.5EEP,PITI5) �
WORKTOHOUSESEWER � AND/ORDRAINFIELD �
� OVERFLOWSEEPAGEPIT.DRAIfYF1ELD GESSPOOL ❑ DRYWEU.❑
E%TN.,CESSPOOL DRYWELL,MANNOIE
� ALTEF.REPAIROHABANDONHOUSE ALTER,REPAIR.SEWEROR
� SEWEF OR OISPOSAL SVSTEM SEWAGE DISPOSAlS�STEM
DISCONNEGT PLUG AND
ABANDON HOUSE SEWEH
BACKFILLSEPTICTANKS❑
��WNER'S
Permit S SEEP,PITI51[� CESSPOOLS❑
AUTHORIZATION TOTAL PEE VALIDATION �T 6 9,2 A .
1 HAVE AT THIS OATE A CONTRACT WRH THE NEREIN NAMED GON- , ' . ' _ a/q � � � 1 O
TRACTOR TO CONNEGT TME ABOVE DESG IBED EXISTING DWELL�NG - � f` �
TOTNEPUBLICSEW x�y, - • � o
SIGNED THIS C DAY OF � t Y P : iI ° �� � G Q U -� -� �
OWNEROR a
OWNERS AGE /� , , � � b I u G O U --'
ADORES$ ` / � �
1 HEREBY ACKNOWIEOGE THAT 1 HAVE READ THIS APPLICATION Q�'O���O
� AND STATE THAT 7HE ABOYE IS GORRELT ANO AGREE TO COMPLY
IWRH ALL GOUNTY ORDINANCES AND STATE LAWS REGULATING '
VLUMBING ANO SEWEFS.
� 1 HEREBV GERTIF�'THAT I AM PROPERLY REGISTEREO ANO/OR
LICENSED AS REOUIRED BY LOS ANGELES GOUNTY AND STATE OF
CALIFORNIA ORTHAT 1 AM THE LEGAL OWNER OF,AND INTENDTO RE-
SIDE IN.THE ABOVE DESCRI6E0 RESIDENTIAL VROPERTY.
� SIGNATURE � � /J � � -
OF PERMfTTEE `�� `L/��
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