HomeMy WebLinkAbout1689A i . - . . , _ ._. .,
76A0�Y� � •
CE808(REV.6/7811/79 APPLlCATION.FOR PERMlT �
�s
: SEWER — SEWAGE DISPOSAL
! GOUNTY QF l05 ANGELES BUILOING AND SAFETY
FOR APPLICANT T FILL IN DISTFICi N0. GROUP MAP PROCESSED BY
BK PG/
� BUILDING � � �r-• /C
ADDRE55 �+ �.7
iCONNECTION DATA
LOCALITY
NEARE57 STATION� DEPTM G�
CRO55 ST.
� / '�/ UPP
i � MAN L E �y OW
OWNER T EOFGONNECTION LENGTHFROM
M'q�� Y. CURB P. M.L.TO P.L
ADORE55
P.C.NO, ��
f • � CO.IMP.NO. �OB NO.
I CRY TEL NO.
LEGAL TRUNKPERMITNO. ROADPERMfTNO.
OESCRIPTION LOTNO. �
AFFIDAVIT WAIVER EASEMENT R6CORD.INSTR.NO. �ATE
�j 9lOCK TRACT
NO.OF BLDGS.
512E OF LOT NOW ON LOT HWY.OR 5T.WIDENING
USE OF �
BUI�DINGS STATE ENGROACHMENT
PERMI7 NO.
CONTRACTOR IMDUSTRIAL
WASTE APPROVAL �
ADORE55 ��J CHARGES
CITV TEL NO. � CONNECTION CNARGE FEE
ISTATE �{ �, LIG. REIMBURSEMENTFEE a
LICENSE NO. V CLA55 � O
� NO. DESCRIPTION OF WORK FEE APPROVALS DAT E TOR' ATURE V ,
HOUSE SEWEF CONNECTING TO � a
PUBIIC SEWER � O
SEPTIC TANK,SEEPAGE PfT OR NEW HOUSE SEWER r
PITS ANO/OR DRAINFIELO CONNECT ADDITIONAL ��
LJ
HOUSE SEWEN CONNEC7ING TO BUILOING OR WORK Q.
PRIVATE DISPOSAL SVSTEM SEPTIG TANK.SE EP,PIT(51 N
GONNEGT ADDfTIONAL BLOG.OR ANO/OF ORAINFIEI.D �
WORKTOHOUSESEWER � �
OVERFLOWSEEPAGEPIT.DqA1NFIELD CESSPOOL❑ DRYWELL❑
EXTN..CESSPOOL.ORYWELL.MANNOIE
ALTER,pEVAIR OR AOANDOf�1 MOUSE ALTER,REPAIR,SE WER OR
SEWEH OR OISPOSAL SY9TEM SEWAGE DISP05Al.SYSTEM ,
� � DISCONNECT PLUG ANO � '
AEAN�ON110USESEWER
sAGKFILL SEPTIG TANKS❑ �
OWNER'S Permit s �� $EEP.PITISIQ GE55POOL5❑
� AUTHORIZATION TOTAL FEE � VALIDATION
• 1 HAVE AT TH15 OATE A CONTRACT WITN TNE HEREI NA ED CON• r T U Q 0 r{
TRACTOR TO CONNECT TME ABOVE DESCRIBED E)(1571NG DWELLING
TO TM!rUBLIG SlWER. {� � � .� � 7 O
1 �
SIGNEDTHIS��DAY OF 19 . '��'
OWNER OR I ° .e r �7 O O
OWNERS AGENt ,
/
AOORE55 � '.o ;,,� � � �0�
� I NEREBY ACKNOWLEOGE TMAT 1 NAVE NEA�TNIS APPLICA710N �
AND 57ATE TMAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY O 7 O�l��O
1 WRH ALL GOUNTY ORDINANGES AND STATE LAWS REGULATING '
!PLUMBINGANOSEWERS. . � ,
I HEREBY CER7IFY THAT 1 AM PROPERIV FEGISTERED AND/OR
'LICENSED AS REOUIRED BV LOS ANGELES COUNTV AND STATE OF
GALIFORNIA ON TMAT 1 AM TNE LEGAI.OWN R Oi,ANO INTEND TO RE- �
,SIDE IN.TNE ADOVE DESCRI9ED RESIDENT�LPFOPEwTY. .
>IGNATURE
OF PERMfTTE E
. . �
, i
FOR DEPARTN1ENT USE
:
C�[C�UIP,ED If�lFO"Er1ATI0i3 �
1. INDICATE ALL BUILDINGS ON PROPERTY. . ;
2. INDICA7E AND DIMENSION SEWAGE D(SPOSAL �
SYSTEM WITH TIE DISTANCES 70 BUILDINGS -
� AND PROPERTY.LINES. � • , • � �
I
3.INDICA7E SIZE OF SEPTIC TANK-DEPTH OF SEEP• , �
AGE PITISI-SIZE OF CESSPOOL(SI.
. �
4.INDICATE NORTH DIRECTION ON PLO7. � � ' - �
5. INDICATE BOTH.STREETS IF CORNER. , �
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I FIELD NOTES � , �. �
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