HomeMy Public PortalAbout5233 ALESSANDRO AVE_Sewer_0 76 E 66 APPLICATION FO■ \ PERMIT
S 8 E 667 3 SS
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL.
Deportment of County Engmeer
County of Los Aageles TI
UILDING p�•^ 3 L
WM J FOX COUNTY ENGINEER
ADD
® CASSATT D GRIFFIN SUP T OF BUILDING OCALITY
FOR APPLICANT TO FILL IN ROSS S
LS�{� • W' SI —,7-517 �A-
DESCRIPCRIP TION LOT I3 NO !aAl Ong OWNER
BLOCK TRACT / 12 2 I MAIL '
ADDRESS
NO
SIZE OF LOT NOWOON LOTS CITY TEL NO
USE OF C4�
BUILDINGS DISTRICT GROUP MAP
CONTRACTOR C v S t' 7BK PG
ADDPESS "�.'2.. �' „� fir y A—/ CONNECTION DATA
CITY j>,.I �y-4,. � TEL NO Fp STATION DEPTH
2}-STATE MANHOLE REFERENCE
REGISTRATION NO � � � ❑ COUNTY — �
LOWER
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO �` TYPE N CTION LENGTH FROM /
PUBLIC SEWER @ $ 3 50L3 CURB ML TO P L Q
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 100 _
CONNECT ADDITIONAL BLDG ORe-- P C NO
WORK TO HOUSE SEWER 1 00 CO IMP NO !-3JOB NO
ALTER OR REPAIR EXISTING
SEWER CIR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANY SEEPAGE PIT OR
PIIS AND/OR DRAINFIELD 00 INDUSTRIAL
CESSPOOL DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
� t
OWNER S PERMIT CONNECTION CHARGE FEE
o0
AUTHORIZATION TOTAL FEE 5-., REIMBURSEMENT FEE
TRACTOR
HAVE TTOS CONNECTDATE ONTRTHEAABOVE DESCRIBED EXCTED WITH THE ESTINGIN NAMED
DWELLAPPROVALS D TE INSPEC OR SSIGNATURE
TO ThE PUBLIC SEWER
SIGNED THIS AY OF t NEW HOUSE SEWER 3 /J
CONNECT ADDITIONAL
OWNER OR
OWNERS AGENT BUILDING OR WORK
'
SEPTIC TANK SEEP PIT(S)
ADDRESS 7z AND/OR DRAINFIELD
I HEREBY AC OWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL[IAND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPi.Y
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM,THE LEGAL OWNER OF THE ABO%E ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL P PERTY BACKFILL SEPTIC TANKS❑
SEEP PIT(S) ❑ CESSPOOLS❑
SIGNATURE
OF PERMITTEE P2&, &
WILLIAM J FOX CO NTY ENGINEER VALIDATION R A WOOD CHIEF PLBG INSPECTOR
7 4 1 C- JUIm 2 6 a 4 50 L�,