HomeMy WebLinkAbout1690A (10) � _ _ - - - - _ -
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CE808(REV.6/78)1/l9 APPLICATION FOR PERMIT
CDf
SEWER - SEWAGE DISP�SAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO Flll IN D�STAICT NO. GROUP MAP PAOCESSED BY
BK PG
B���o,N� D s a � o"� 3 �E /�
ADDRE55
-- ---__---,__----. --- — _ CONNKTION DATA
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LOCAIITV � ���' ---"""-
NEqREST - - � STATION i� �'1 DEPTH �/ .
CRO55 ST. � f -
Q�� E R
MAN L E d LOWER
OWNER
MA'L T PE OF GONNECTION LENGTH FROM /f
AODRE55 Y. CURB P M.LTOP.L m�
P.GNO.����J
CO.IMP,NO. JOB NO. �
CRY TEL.NO.
LEGAL TRUNKPERMITNO. qOADPERMRNO.
DESGRIPTION LO�NO.
� AFFIDAVIT WRiVEN EASEMEhT REGORD.INSTR.NO. DATE
BLOCK TRACT
NO.OF BLDGS.
I 512E OF LOT NOW ON LOT HWY.OR 5T.WIDENING
USE OF
� BUILDINGS sTATE ENGROAGh1MENT
PERMITNO.
GONTRAGTOR � ■ �NOUSTRIAL
WASTF APPROVAL
ADDRE55
�U' GHARGES
/] CONNECTIONCMARGEFEE }
CITY TEL.NO, ��
STATE IIG. REIMBUNSEMENTFEE " n"
LICENSE NO. � CLASS \ Q
NO. DESCRIPTION OF WORK FEE � APPROVALS DATE IN OR'S SIGNATU V
HOUSE SEWERGONNECTINGTO
!!C
PUBLIC SEWER ' � O
SEPTICTANK.SEEPAGE PIT OR , , NEW NOUSE SEWER �
PRS AND/OR DRAINFIELD CONNECT A�ORIONAL
lW
� HOUSESEWERGONNECTINGTO BUILOINGORWORK �
� PRIVATE�ISPOSA�SYSTEM �
CONNECT ADOITIOh1AL BLDG.Ofi SEPTIC TAN K.5 E E P.PITI5) ?
WORK TO HOUSE$E W!R�� - AND/OR�RAINFIELD �
OVERFLOWSEEPAGEPIT.OR4INFIELD CESSPOOL ❑ DRYWELL❑
El(TN..CESSPOOL,ORYWELL.MANHOLE
� ALTER.REPAIR OH ABANDON MOUSE -� 4LTER.REPAIR.SEWER oR
SEWER OR DISPOSAl5VS7EM SEWAGE DISPOSAL SYSTEM
� � DISCONNECT PLUG AND ' ' -
ABANDON FIOUSE SEWER
� B.>CKFIlLSEPTICTANKS❑ . . , . ..
+ Permit s �'� SEEP,PITI5)❑ GESSPOOLS❑
OWNER S C`, VALIDATION < 1'6°,0 A
AUTMORIZATION TOTAL FEE
1 NAVE AT THIS�ATE A CONTRACT WITH THE HEREIN NAMED CON• . . . .{�*e� � � � n
TRACTOR TO GONNECT THE ABOVE DE$CRIBED EXISTING DWELL�NG w \i
TOTHE PUBUC SE R. ' � • �
�SIGNEDTHIS- DAY OF � 1�D i �) 'O!� q U O O �� -
'�WNEp OR � p
)WNERS AGE�T� � � � • ? � � C:.O O U �
DDRESS , q /�
I HEREBV ACKNOWLEDGE TNAT I HAYE READ THIS APPLICATION I D 7�O 8�C�l,'
AND STATE THAT THE ABOVE IS COHRECT ANO AGREE TO COMPLV '
WITH ALL COUNTY OROINANCES AND STATE LAWS REGULATING
PLUMBINGAf�IDSEWERS. . � �
I HEREBY CERTIFY TMAT 1 AM PROPERLY REGISTERED AND/OR
LIGENSED AS REOUIRED 6Y LOS ANGELES GOUNTY AND STA7E OF
CALIFORNIA OR THAT I AM TME LEGAL Cf WNER OF.ANO WTEND TO RE• .
SI�EIN.THEABOVE�ESCRI6EDRESIDENTIALPROPERiY. ' . �
SIGNATURE -
OF PERMITTEE
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