HomeMy WebLinkAbout0918A _
� �
�aaba24 .
C�t808fR�V.6/7B)1/79 APPLICATIOIV FOR F�ERMIT -
�S
SEWER - SEWAGE DISPOSAL
� COUNTY Of LOS ANGELES BUILDING AND SAFETY
FOR APPIlCANT TD�I�LL IN DISTRICT NO. GROUP Mnv PRo�e o Y
•\ L7' � PG S
eui�oiN� /' Ct 1�
ADDRESS �
� �� �� CUNNECTION DATA �
I.00ALITY
NEAREST STATION r. O "� DEPTH
CROSS ST. ��
" ' MANHOLEREFER6NGE "1�
OWNER �' ,�^' �Ia:�A/� 'G� LOWER' "I
TYPE OF CONNECTIO LENGTH FROM �
MAIL • w �1 V. CURB P.L. � M.L.TOP.L. ,�
ADDRE55 4' 'd. •' P.G.NO. [7 ��
� � {���y �.,�.,,/°��4� CO.IMP-NO. J08 NO. X � �
CITY �. TEL NO. / �
LEGAI � 7RUNK PERMIT D10. ROAD PERMIT NO.
DESCRIPTION LOT NO. C� C�
SA$ . � AFFIpAVIT `NAIVER EASEMENT RECQRD.INSTR.NO, DATE .
BLOCIC TRACT j
(��� NO.OF BLOGS. /�
SIZE OF LOT � � ~ �,/� NOW ON LOT 4+' HWY.OR ST.WIDENING
USEOF " "
BUIL�INGS -��y� • S?ATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
CONTRACTOR .-'�+�y4S,f WASTE APPROVAL
ADDRE55 GHARGES
CITY TEL NO. ^.yLq,/L�or�. GONNECTION CHARGE FEE
°�'
STATE . , "'---��'� � �' LIC. REIMBURSEMENTFEE 4"
LICENSE NO. � ' 7 � CLASS � �
NO. DESCR�PTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE � ,
HOUSE SEWER GONNECTING Tb' ' �.��J �/y
I PUBLIG SEWER ' � $'f {,d� � Y✓
SEPTIC TANK.SEEPAGE PIT OR NEW HOUSE SEWER � ��� ,�'i��� Q/Li �
PITS AfYD/OR QRAINFIELD � ' � CONNECT ADDITIONAL
HOUSE SEWER CONNECTING�TO BUILDING OR WORK � E4,
PRIVATE DISPOSAL S�`STEM � �
CONNECT ADOITIONAL BLDG.OR� SEPTIG TANK,SEEP.PI7157
WORKTO HOUSE SEWER �� �-�� AND/oR DRAINPIEID
OVERFLOW SEEPAGE PIT,ORA�NFIELO GESSPOOL Q DRVWEIL❑
EXTN„CESSPOOI,ORYWELL,MA.NHOLE
ALTER,REPAIFi'OR A6ANDON HOUS'E ALTER,REPAIR,SEWER OR
SEWERORD15POSALSYSTEM '- � SEWAGEDISPOSALSYSTEM �
' "� � pISCONNECT PLUG ANO
. ABANOON MOUSE SEWER
y� BACKFILL SEPTIC TANKS[]
QwNER�s' Permit ,. $ a / �� SEEP,PIT(S),.,J CESSPOOLS❑
AUTHORIZATION TdTAL��E � VAUDATtON
I HAVE 0.T THIS DATE A CONTRACI"�111I17H�THE HEREIN NAMED CON-
7RAGT4R TO GONNECT TNE ABOVE�[SESCRIBED EXISTING OWELLING
TO TNE PUBLIC SEWER. ' ' ' �
SIGNEDTHIS DAYCJR� � 19�
OWNERS AGENT ............. .. �Q 4 ��H 7'4
ADDRE55
. . # • • •���.� O
I HEREBY ACKNOWLEDG6 THAT I HAVE READ THIS APPLICATION
ANO STATE THAT THE ABOVE IS CORRECT ANp qGREE TO COMPIV o /'�
WRH ALL COUNTY ORDINANCES AN❑ STATE LAWS RE6ULATING I;•�.� � U4O V
PLUM6ING ANO SEWERS.
1 HEREBY CERTIFY THAT I AM PROPERLY REG�STERE� ANpjOR � �Q O�
LICENSE�A5 REQUIRED BV 4Q5 ANG5LE5 COUNTV AND STATE OF �0.� �
CALIFORNIA OR THAT I AM THE LEGAL pWNER OF.AND 1 TENDTO RE-
SIDE IN.7HE ABOVE DESCRIBE�FtE51CIHNTIAL PROPE . �
' � � Of� 1 0�8D
SIGNATURE '
OF P�RMITTE °�
I . ,... . . . .... , . . r' Y;
�;�'
" FOR d9EPARTl��ENT IJSE
�E�6l6����s���3� .Ti�f�
t. INDlCATE ALL BUiLDiNGS C)h; PRQPERTY_ ���
2. iR1DiCAiE AND Di,ViENSiQN ScVti'AC�E DISPOSAL
SYSTEI�', W4TH T!E D4S7A�vC�S i0 BUIlDiNGS , °''
AlVD PRQPERI'Y Li�lES. `; ' `�, +'
3.if�iDiCATE Sl�E OF SEPTIC 1'ANK-DEPTi� OF SEEP- ik
AGE PiT(Sl-SIZE OF CESSPOOL(SI. ;';'i
4. lNDICATE NORTN DIRECTION OfV PLOT. �
• 5. 9ND(G�,i'E BOTH STRcETS!F CO�tN�R. ,
S7.A�LEY Rt�lel
FIELD NOTES
� �';�K ,