HomeMy Public PortalAbout5937 ALESSANDRO AVE_Sewer__ 76AE 66 APPLICATION FOR PERMIT 1
e DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE D I S POSA L
Deportment of County Engmeer
COUIItp of Los AIIge108 BUILDING
WM J FOX COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL NEAREST V
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LEGAL J 1
DESCRIPTION LOT NO 11.4 7'0 OWNER
BLOCK TRACT �a ch- .x � y,�`', ADDRESS S 9 *b /NO OF
CtX..t/l�l cc 'D
SIZE OF LOT Sr6 X I 5-0 NOW ON LOTS .2— CITY TEL Ivo 17 '1
USE OF
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BUILDINGS e'— DISTRICT NO GROUP I MAP
BK PG
CONTRACTOR 1 � /
ADDRESS r CONNECTION DATA ./!�
CITY T L NO STATION �'� DEPTH
JL ❑ STATE MANHOLE REFERENCE q..r UPPER
S�� IRMR
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REGISTRATION NO /y ❑ COUNTYy�
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NO DESCRIPTION OF WORK FEE -
HOUSE SEWER CONNECTING TO TYPE OF NNECTION LENGTH FROM
PUBLIC SEWER Q $ 3 50 '� URB,
RB t!: M L TOP L
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100 _
CONNECT ADDITIONAL BLDG OR ) P C NO
WORK TO HOUSE SEWER 1 00 CO IMP NO /, f JOB NO
ALTER OR REPAIR EXISTING
SEWER OR 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
PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
OWNER S PERMIT
$ 00
AUTHORIZATION TOTAL FEE cl REIMBURSEMENT FEE
TRACTORHAVE TTOS CONNECTDATE ONTRTHEAABODVEWDESCRBED EXIISTINGITH THE HEREIN p FDWELLING ED CON APPROVALS DATE INSPECTOR SSIGNATURE
TO THE PUBLIC SEWER ,,q�7�
SIGNED THIS DAY OF �' 19J J NEW HOUSE SEWER _ _ rI
OWNER OR CONNECT ADDITIONAL (�.A
OWNERS AGENT U.-LAA
�o�q BUILDING OR WORK
ADDRESS----%-f:: '3 7 U.-LAAAI�' I �� SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEPEPY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL[:1DRY-WELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS ALTER REPAIR SEWER OR
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 I AM THE LEGAL OWNER-OF THE ABOLE ABANDON HOUSE SEWEP
DESCRIBED RESIDENTIAL ROPERTY BACKFILL SEPTIC TANKS❑ /LI. / �
� SEEP PT(S)
❑ CESSPOOLS c
SIGNATURE
OF PERMITTEE
WILLIAM J FOX COUNTY ENGINEER VALIDATION R A WOOD CHIEF PLBG INSPECTOR
iCo 9 3 0 5 L^ OCT 2 4 4
650 '�