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HomeMy WebLinkAbout1681A (10) � :� - r - _._ : : � r � � � �bna.�n. . ,_ � � _ �. . . .; > : �E�e(REV 6I78)1/79 APPLICA`�"T�N'�`0�2��ERM IT __ �, , s��iv�R ���nr�� �is�w�sAt� � �-, - . COUNTY OK LQS AN��LES � � � B�J�LDI(�f�i���AA1D SAFE7Y ��� � �� . ._. � , E. . . _. . �_ a a TOR APPLICANT�SO�F�LL IPB � �ISTkICT.YD.� �GROUP � MAP � �PPOCESSE�Bv � - -����� BK��++ PG/1 � BUILDING" ,�" � �� ��r .. ..y . ADDRE55 e� � , CONNECTION DA7A "�" �LOGALITY . . . NEAREST � � -� STATION�' DEPTH f � GROSSST -� -�.�. ` . . : ..-:�I't��I _y� UPP R - ��� . MAnMOL�RE� GE�� i�� �� �OWE OWNER . � . T P O G C ON. LENGTHFROM� MAIL � ��"� . � Y. GURB� .L. M.L.TOP.L ADORE55 y� . �' ' . . . ./ � GITY' � TELNO.�� v GO..IMP.NO. ... . JOBNO.�.�S �.� .. .:'LEGAL - � � . - .. �TRUNKPERMITYJO. � '� RDAD.PERMRNO. �-� �E$GRIpTION LOTNO. �' � ' � � � �� . � AFFIpAY1T .IVAIVER EASEMENT REGORD.INSTR.NO. DATE 6�OCK �' ' �TRACT � � No OK''HCbY�S. .., ,,.: .,. ._... . .. . .. ...... . ... . . � 512EOFLOT� � NOWONLOT � �� � HWV.ORST.WIDENING.. � - � USEOF .....'..... ...'�. . . . . . . . . � 9VILDiNGS ", � � ' STATE'ENGROAGHMENT. �� _,�,� _ '- _, - � PERMITNO. � - ._.. .. . ., . . .... IfJDU5TRIAL . . . ... .... .... ... . ..... CONTwACTOR WASTEAPPitqVqL ....� ./'q . .. . . . _. .....,..... ADOR£55 � `j � d ' CHARGES . y.�. . ... , .... ..__....,.._. GITV� � � ,�� g[,ryp, . ,a - GONNEGTION CHARGE FEE � " STATE LIC ' � � �r� �^'+ L REIMBURSEMENTFEE' LICENSE NO � L1 ,�J � CLA55 g - � NO. DESCRIPT(ON OF WORK � FEE � APP�VA� DATE P CTO ' SIGNATURE � HOUSESEWERCONNECTINGTO `��� � � �g � PUBLICSEWER � � � � y �.- V� � .SEPTfCTANK;SEEPAC.+_EPIYOR ""' . � NEWHOUSES,Ey1ER... � � � (.� PITSAND/OROFAINFIEIq CONNECTA�GGI'JONAL� � � BW �HOUSESEV/ERtOfJ/Y�GTINGTO ""�' � � BUILDINGORWORK d PRIVATED�SP,OSA4g�5TEM� � SEPTICTqNK,$EEP,PIT�51 �� - � CONNECTA�.pITiONAL BLOG.OR _, . ANO/OR ORAINFIEID - �WORK�TOMOUSESEWER�� . � "�OVERF40WSEEPAGEPIT.�DRAINFIELD�" - . CESSPOOL.[�,ORYWELL.Q �EXTN,CESSPO�L.➢pYWELL,M3INHOLE� ALTER.REPAIR ORABANDON HOUSE � � qLTER�.REPAIR�SEWEF OR � � ' ' � � SEWERORO15PO5ALSYSTEM �� ' ' �- SEWAGE.OfSPQ5Ati5Y5TEM; � � � �ISGONNECTPLt1GANp . � .. , ._ . qBANOON.HOlJSESEWEji „ BACKFILLSEPTICTANkS,[]�. � Permlt $ � � SEEP,PRISI�GESSPODLS-';❑ OWNER'S VAIIDATION AUTHORIZATION TOTAL FEE ' <<? 4�$'1 P, I NAVE AT THIS�ATE A COMRACT WITH THE HEREIN NAMEb CON-. TRAGTOR TO CONNECT THE ABOVE OESCk�BED EXISTING OWELLING '��T07HE PU6LIG SEYy�R ' � �� "' �' ` �I9 6 S � R G S�GNEDTHIS L'� '.�AYOF 15Q_� � � - l (�+ ' OWNER OR '�'.k� �?�"�..tJ� ... , � OWNERSAG�E� ' . .., .. ..!. ,.. • p L♦/�T..�.. ARltiR699 "' G7 .. � .•.?k'' �µ..1�1'J;:J ... 1 H�fiEBV kC1ffJF3WL,EO6E THAT 1 HAVE RERD TH15 ApPLIGA7ION +�n p Q ANb STA7P.�'THIiT,THE„ABOVE 15 CCRRE T AYJb AGREE"'TO'C6MPLY � �� r�V t% '�G-� � -- WITH iSLL""GOVNTV'�ORISIN�JGES ANb�tATE LAWS'Ii�GUL`/�TTfl:G � . � � PLUM6ING AND SEWEH9 - ''1'HEpEBY LEi�TIFV THAT I���_Y(M PROPE.SiLY�p EGISTE�R�E�AN�/OR . � _IGENSE�"A5R1EqUIR'EfS�Y"C'i5$A�'1'G�`LES`COUFfY1"A'IVp`§TAY�''OF ' �:AL�F(FRNIAtlRTNAT1.41NTliEY:EGALdlVl:lEp�dFAND1IVTENb'TO�kE- ' IpE 1!J`TYiEA84V�S'l�SCiFIB.fEDY2�51DEf7�fAL�R`OPEi�TY.�' , ' � IGNATUR'E� �, r-i�{^-„p/\ . .... . � . OFPEkM�EE vV-" --- � � . _ � €���€�A�t��t��t�s�..: ..�. . ...:. .... .. _ . . _.._., ����s������o ��t�t�' _ . _. : .. __: .. 1.INS}I�ATE ALL BUILDiNGS ON PROPERTY. � 2.1NDICATE AND'�lMENSiON SE\NRGE DlSPCSSAL SYSTENI WI7H 71E D1STA'NCES TO 'BUSLDINGS" AND PROPERTYLINES. ' . _ 3.INpICATE SIZE OF SEPTIC TANK•D�PT�T�F�S€ER ' AGE PIT(S)-SlZE QF CE$SPOQLiSD: ' r, 5 �.. , 4.INDICATE NORTN�IRECTIOi�f ON PLOL ; 5.INDItATE SO7H5TREET&IF C�RNER. ' � 1 ... .ST:ALLEY R/W � . . .�.». FiELD NOTES .. _ _ _