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HomeMy WebLinkAbout1094A (5) ,I : . �. �Yu . � 74A642D CE808iREV.6/78)1/79 qPPL.I�.ATI�I�➢ F'�t� P�RM 6T , ,._ �� �E1!\/EF2 - ��1IIOA�E t�l�['�SAL. C041NTY OF 4,05 AhIGELES �191L�ING AND SAFETY FOR e4PPILiCAN'f TO FIL!I!d o�sTR�cr r,o. c UP MAP PROCESSED BY �,/� �y BK ,,//��PG + BUILOING �! f � ...+lY ��+ � ADDRESS� � � 4J B� ��" � CONtdECTION ATA LOCALITY �'�� n . / ` NEARE5T d STATION �'� DEPTH 6' CROSS 57. F . UP a � MANHOLE REFEREfdCE OWNER � TYP[OP CONNEGTION LENGTH FROM MAIL �"'j �� ''� Y. CURB P. . M.L.TOP.L. ADDRESS . ' - � '� CO.IMP.NO. JOB NO. ��� CITY TEL.NO. ���„��� - LEGAL /° TRUNK PERMI7 NO. ROAD PERMIT NO. DESCRIPTION LOTlVO. i �� p AFFIDAVIT WANER ERS[MENT RECORD.INSTR.NO. DATE HI,OCK TRACT NO.OF BLDGS. S12E OF LOT NOW ON L07 HWV.6R ST.WIDENING USE OF BUIL�INGS STATE ENCR6AGHMENT PERMIT NO. C4NTRACTOR � � INDUSTRIAL ' WASTE APPROVAL ADDRE55�1 �� r ^ ♦ CHARGES C. �� CONNECTION GHARGE FEE CITY TEL.NO. — ��^ � � STA7E f � LIC. '� /' ,ry REIMBURSEMENTFEE pq I..ICENSE N0.�� ,� � CLASS .....�J �^� ? ' i�i No. . DESCRIPTlON O�'WORK FEe ���� � /4PP���,��,5 DATE INS .OR' SIGNATURE �p . HOUSE SEWER CONNECTING TO // � PUBLIC SEWER {e3 SEPTIG TANK,SEEPAGE PIT OR � NEW HOUSE SEWER � PITS AND/OR DRAINFIELD � CONNECT Ap017lQNAL E9,S HOUSE SEWER CONNECTING TO BUILDlNG OR WORK �k. PRIVATEDISPOSALSVuTEM � - � GONNECT A�DITIONAL OLDG.OR S£PT(C TANK,SEEP,PIT�S) WORKTO HOUSE SEWER � ' - APdn/OR pRAINFIELD ' , OVGHFLOW SEEPA,raE PIT,ORAINFIELCJ CESSPOO� [] DP2YWELL❑ EMN.,CESSPOOL.,ORVWE�L,MANHOLE ALTER,REPAIR'OR ABANDON HOUSE�� �- qITER.REPAIR,SEWEft OR SEWER OR DIBPOSAL SYSTEM SEWAC3E DISPOSAL SYSTEM - ' -� � � --� � - ' � � DISCGNNECT PLUG AND ABANDON HOUSE SEWER BACKFILL SEPTIC TANKS❑ � � SEEP.P!T(51❑ CESSPOOLS❑ OVlInIER'S Permit s AIdTHORIZATIOhI TOTAL F@E � �r RIALIDATIOfV I HAVE AT 7HIS DATE A CONTRACT WITH THE HEFiE1N NAMED GON- TRAGTOR TO CONNEC7 7HE ABOVE QESGRI6ED EXIS7ING DWELLING TOTHEPUBLICSE -� i �'rj�';Ff. ��, . SIGNES?THIS CIAYOF � „_7,,,,...,,1� ,�, � �, /� OWNER OR �/ �� �) tr � � ��� � l.; OWNERSAGENT � ��+.$__� ADDRESS >� `� ;a�� �5:��`,: 1 HEREBY ACNN�WLEDGE THAT i HAVk READ 7H15 APPLICATION { ����. r-i�, AND STATE THAT TME ABOVE IS CORRECT AND AGRES TO COMPLY � ''� �' �� G.�..�;4i C:J WITH ALL GOUNTV ORDINANCES AND 5TATE LAWS REGULATING PLUM6ING AND SEWERS. . 1 HEREBY CERTIFV THAT 1 AM PROPEftLY REGISTEREb AMD/DR '��' �����C�'^-s'4�, , LIGENSED A5 RE!]UIRED BY L(j5 ANGELES COUNTY ANp 3TATE pF CALIFORNIR OR TNAT I AM THE LEGAI.OWNER OF,AND lNTENC?TO RE- SIDE IN,THE A90VE DESCRIB�D RESlDENY'! � -ROPERTY.� � � � SIGNATURE OF PERMITTEE � � ,i . . . . . . . . . . ���C�����36�E�T�I�� ���a��������ta�R��,�'��� 1. i�'E�IC�I'E A.LC �UiL�ilfti!,�',�S OP�3 P�?�PcRTY, �,�.�. �� 2. lNDE�/�iE A'�� ��rvl�ta!;(�N S�'N�.GE C��SPJS�4L 5'�'5TEl�li �'dTH T;E f�ISTI�hlCES 3Q BI�l�C�1i°�,i�S � , ,� : ~ i� " ,��; Afal�PR�n��2i"Y L(fe;ES, , w �": � ' -g:. , . 3.Ih�DI�/kTE 5S?u t�� SEPTiC Tl�6�K-1�EP�i"Fa �i-5���- � = ' '" ' � � :,, ` AC'aE P3S{S!-Se�F CJI=�ESSf'�Ji?L!fi). ,.. �, ;i,.�� a ,'e .;; �:,� 4. !i�lalC:ATE NC�PTd��i�:�CTIC�i'UIv PLC1T. _ � �:; �� � ..� � ,.;�:� .,�,�;,��s':�; -� 5. I�ig2i��7E 6�T'ri STRE�9'S iF���f�l�R. , ,.. . .• . . "� r _, ... . ....._.. �,� i_• � � `�._,3�..*t ':l�� s��W. i{ l , ,�; a .. ,•� , 'ti,,�,.�` „ , r� ,. �J'4 `.. 3.r +..s�.,,. �s ,� . : '��..� ;� <:,,�� i �.; . . � �.e�:._ .y�^:P �� - :k5..,s t � . . � .._ .J . _ � . 5.,,.. � Y,..�,_�.^a�' . � �F.���.���,� �������4�$ ._._._,_._,,.e_- _ _ , . .. „k �-?, � � . , . �.� � - - —"__�� �_. � s... .� .,... . . � ,. -:+�..._. ....�