Loading...
HomeMy WebLinkAbout1057A (5) . . ..�. ... . .. .. i .:.;..'. . . , -�. � .�.:,..:. _..�.,. ., .:_, �. . ..._.,. _,i��; .r. �:' , :,:5 .4. . , , . . . . . , ...- .. . �.' .. . .� 7bA6d2D CE808(REV.6/7B)1/79 ����� /��� � �.'^ � ��� iT OO s �i� [-- � ��W!/EF2 - S�iOlIACE �3��1��a/�i.. GOUNTY OF LAS ANJGELES Bl,rllCStMG AfVD Se4fETY E'OR I°ePPLICAOV i IAJ FBLL�I� �ISTRICT N0. G P MAP � PROCESSED BY 6J( PG BUILDING �� •p� 0 ���J2� � ��✓° ��•+-� ADDRESS „/ �— ^ E7 COn4d�D@CT601d D/�TA IOCAL,ITV j �', JEAREST � STATION /1� ✓ DEPTH ' 3R055 ST. � • dP G' r UPPER OWNER���/���_� �� / G)l�.� � MANHOLE REFERENCE - �� � OWE —11� � TYPE Of'CONNECTIOM-� � LENG'1'H�FROIVI� - MAIL � �""� Y, CUR6 P , M.L.TOP.L. .ADDRESSG _��� r r �/ P.C.NO. C� ��(��� TEL.NO. ��!.f�f CO.IMP.NO, JOB NO. .��� F_GL,_r LEGAL �/ TRUNKPERMITNO. ROA�PERMITNO. 'DESGRIF+TIOIV LOTNO. Cr — s� AFFIDAVIT WAIVER EASEMENT REGQRD.INSTR.NO. DATE BLOGK TRACT �(..�'�.� NO.OF BLDGS. ' - SIZE OF LOT NOW ON LOT NWY.t7R ST.WICIENING USE OF BUILDINGS STaTE ENCROAGHMENT PERM IT NC. " INDU57RIAL GONTRAGTOR 7� �'II. _ � WASTE APPROVAL —� � �j,/f ADDRE55��� f�G�'=—'"— �C GHARGES� GONNECTION CHARGE FEE �CITY ,4 7EL.NO.��� �-�/3�J _ 3+. �STATE .� LIC. /'y� REIMBURSEMENT FEF_ � ' LICEN5EN0.�..�j �� CI�.SS S„ ���„ NO. 6ESCRIPTION(3F WORK FEE ��P��V�L$ � DAT�• i -GTpR' SIGNATURE � , HOUSE SEWER CONNEGTING TO .v`1�9'f � � PUBLIC SEWER ��9 NEW HOUSE SEWER ¢� SEPTIGTANK,SEEPAGE�PITOR � � PITS AND/OR DRAINFIELD CONNECTADDITI[]fdAL 5�79 HOUSE SEWER CONNECTING TO BUILDING pR WOF2K �9. PRNA'7E I315POSAL SYSTEM � � � CON�IECT ADDITIONAL BLOG.OR SEPTIC 7ANK,S6Ep,PIT�5) AND/OR Di?AINFIELD � WQRKYO NOUSE SEWER �— � OVERP=LOW SEEPAGE PlT,DRAINFIEL� ,CESSPOOL ❑ �RVWELL[� EX7N.,GESSPOOL.DRYWELL,MANHQt_E _ ALTER.REPAIR OR ABANDON HOUSE' -- " '�- AITER,REPAIR,S�WER OR SEWEROR DISPOSALSYSTEM SEWAGE DISPOSALSYSTEM - ,.DISCONNECT PLUG AND 'ABANpONHOUSESEWER �ACKFILL5EP71CTANKS❑ � SEEP,PIT15)❑ CESSPfJOLS❑ Oyy'IVER'S Permit $ V �l,4al DB�TlON �lUTWOPkI�°BITION TOTAL FEE �� I HAVE AT THIS DATE A CONTRAC7 WITH THE HEREfN NAMED GON- . �`�' '�°�7,, I �� TRACTOR TO CONNECT 7HE ABOVE DESCRIBED EXI571NG�WELLING TOTHE PUBLIC SE E ,1 ��� � �� ,� ,� ,.� SIGNEDTIiIS DAYOF 19�L' , �'"� -� � 6 ^p p OWNERS AGENT _ 'P '�^ �� �p V,�{+ , ADDRESS_ f.��.,c�- f(4 � �'' h� � U��t l.i'� . ' I HEREBV ACKNOWLEOGE THAT I HAVF_ REAO THIS APPLICA710N � � AND STATE THAT THE ABOVE IS CORRECY AND AGREE 70 COMPLV W(TF9 ALL COUNYV ORDINANCES AND STATE LAN/S REGULATING � �,'. '� ������? �� PLUMBING AND SEWERS. � '- ' -' ' I HEREBY CERTIFY THAT I AM PPiOPERLY REGISTERED ANp/OR LICENSED AS REQUIRED Bl'LG1S ANGELES�COUNTY P.ND STATE OF' GALIFORNIA ORTHAT!AM THE LEGAL OWNER OF.ANO IIVTENO TO RE- SIDE IN,TH�A00VE DESCRIBED RESIDENT l,PROPERTY. � - 1 � SIGNATURE OFPERMITTEE ' ��,Q � i� , . .. . , . , . . ,,. . . . .. . . . . . _ . . . . � ���..,..�......_._.»_»...�.�.,..� . m . ..� .. . . ..�w....�...�7�-..»...»�.........,..>...:�... . __ __.�._.__e�.: ��������fi����4iS� ����.�€�s;�3����m���3'��3� r t. iNt71C�,ic �1s�! B:.fi�.�ii��S �I�! �'2QPEt27Y. , 2. {�i�dClaT� AN� �iJ�1Ei�;5��� SE'aV��GF t�ISP�SAL SYSTEt!�t 1fV?�'�-+ i3� t?iSTAE'���5 T� ElJIl.f�i����� . � Ai`�1c"�P��P3�Ri`�`L(f�a��. , ' 3.il�l�ICr°1a� Si�� �� S��`EP� !r�[4ii:-��PTI-i CDf=SEEP- , ., � Flr���ITlS!-S3:GE�F�E�S'�L)L(SP. � � .w. .,�. '� , s.�, 4. 8�1C7fCPT�N£�i2TFi Cii�ECTI(�6�4 C'iN P�t�T. >'_; ,"��..0 �4:z ,.�.:� �= ; ` .,�.,�'. �,., .�- r S. il�t?9C;�T�BC�T6-1 STRE��'�[F��el�E�. . . " . " ' � . . ., . �. � .. ; . . . Y r ... �.�a . .. ... . , .i-Y'..,,' . ':.;t� , � .,. , . .� . . . ,. ...� .. � ":s..a�. .:,� � . .. , ; .: F� . : �.+t,: ""t, .r'.:A.i a kti,,]��...J ..,�y'iY:�} � ... �_ «. r. m.. . 'S..i' i ;�,� . , . � . .. . _ ..w y '�ky .� . . .,.i; tw .. i..� ' , - . . sr,������;;� ` _ ;.� FiELE�t��TES , - . • _ . 4 %'�. 3� �-i� ;,..�., , � . - � . ,. ',,+. � --- �..,.e..a...� ��_____ :� �......�_.a__�.�....�.............�.�._�.....�e._.._.. ,�� 1 . . ... , . ., . �. .. . . . . I'� � .�__.__. , ...._._ ' � e�s�.asd. �...��, ��. - , . . ' .I