HomeMy WebLinkAbout1691A (10) 76A6t2D ' , �
CEBOBIREV.E/78)1/79 APPLICATION FQR PERMIT
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SEWER - SEWAGE DISPOSAL "
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPUCANT T FILL IN DISTqICT N0. GROUP MAV P0.0CESSEO 6Y
BK PG
BUILDIf�G 0 a �9 E� / / .
♦DDRE55-- � ((I
• CONNKTION DATA --
IOCALITY
NEAREST _ STATION�-�r/ DEPTH 6
CROSS ST.
�� UPPER
L _ .._-........__.._._. MAN F ENCE s ' ER
._ __-._ _...._._ _ . .
""_"". _ '_ _'- .
......"_" _ .
, OWNER - ..'._._.._ ..
.. . .. . 7YPE OF CONNECTION LENGTH FROM . .
� MAII . .. . . . . . . _. Y . .. Ci1RB. .L M.LTORt�
A��R655
� P.C.NO. �/
CO.IMP.NO. JOB NO. �5
CITY TEL NO,
� LEGAL TRUNKPERMRNO. ROADPERMITNO.
� DESCRIPTION LOTNO. -
_ AFFIOAYIT WAIVER EASEMENT RECORO.INSTH.NO. DATE
BLOGK TRAGT
� O.OF BlDGS.
5¢E OF LOT NOW ON LOT NWY.OR ST.WIDENING
USE OF
BUIL�INGS STATE ENCROACMMENi
PERMIT NO. �
GONTRACTOR �NDUSTRIAL
WA$TE MPROYAL
AOORESS ! �� CHARGES
CITY TEL NO. GONNECTION GHARGE FEE
�
STATE �) -�- LIG. -��- - � REIMBURSEMENTFEE.. �
UGENSENO. V GLASg � � � � � � �- -- O
� NO. DESCRIPTION F WORK FEE APPROYALS DATE �NSP T 'S NATUR u
HOUSE SE WER CONNECTING TO �
PUBLIG SE WER '
SEPTICTANK,BEEPAGEPITOR � NEWHOUSESEWER � O
PRSANO/ORDRAINFIELD CONNECTADOITIONAL � �
W
NOUSE SEWERCONNECTINGTO � BUIL➢ING OR WqRK '(�,
PRIVATE D15PO5AL SVSTEM y
SEPTIC TANK,SEEP,VRIS)
CONNECT ADO(TIONAL BLDG.Oq ANO/OR D RAINf�ELD �
WOPKTOHOU8E9EWlR �'
+ OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL
! EXTN.,CESSPOOLDRYWELL,MANMOLE ❑ ORYWELL❑
� ALTER.REOAINORABANDONHOUSE ALTER.REPAIR.SEWEROR
� SEwERORO15PO5YL5Y5TEM SEWA6EDISP03ALSYSTEM
� D19GONNEGT PLUG AND
ABANpONNOUSESEWER
BAGKFILL9EPTIGTANKS� . .
� Permit s � slEP.PITISI�CESSPOOLS❑
OWNER'S
` AUTHORIZATION TOTA1 FEE ' / VALIDATION � 1 6 9,1 A
1 HAVE AT THIS bATE A CONTRACT WITH 7HE HEREIN NAMED CON• �7 0 � � L � O
� TRACTOR TO CONNECT THE ABOYE OESCRIBED EX�STING OWELLING t .
TOTME PUBLIC SEW R. q p
SIGNEDTHIS OAY OF 1��{ � � . � � `� 1 • �I O�U O �
OWNEROR [�
OWNERSAGENT a F 'e � C���O U
ADORE55 ' �' � �7 p
I HEREBV AGKNOWLEOGE THAT 1 HAVE READ THIS APPLICATION � - O 1�O U+��O �- .
AND STATE 7HAT THE ABOVE IS GORRECT AND AGREE TO COMPLY
WRH ALL COUNTY ORDINANCES ANb STATE LAWS REGULATING �
PLUMBINGANDSEWERS. � - -
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
IICENSED AS REOUIRED 6Y l05 ANGELES COUNTV AND STATE OF
CALIFORN�A OR THAT I AM THE LEGAL WNER OF,AND INTENDTO RE-
SIOE IN.THE ABOVE DESCRIBEO RESI NTIAL PROPERTY. -
� 51GNATURE 19_ � �
OFPERM(TTEE ��"�
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