HomeMy Public PortalAbout9020 ACASO DR_Sewer_8/29/1955_sewer connection' — Xdt-673 3.55 D APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING
ADDRESS
WM.J. FOX. COUNTY ENGINEER
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY n.
FOR APPLICANT TO FILL IN NEAREST
CROSS ST,
LEGAL
DESCRIPTION LOT NO OWNER I
BLOCK TRACT '- dot-_77;_ AIL C7
-ADDRESS
N0. OF BLDGS. /
_SIZE OF LOT NOW ON LOT / CITY TEL. NO.
USE OF
BUILDINGS % rAz DISTRICT NO. GROUP MAP
BK PG
CONTRACTOR � .,,,/ / � `� t")
ADDRES / CONNECTION DATA �—
CITY TEL. NO. ?—A y STATION / 4- DEPTH
/ Er STATE MANHOLE REFERENCE .7/ tom/ r- UPPER
REGISTRATION NO. �/ L� ❑ COUNTY - 41 :2f-
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO ,>-Y. CURB P.L. M.L. TO P.L.TYPE OF CONNECTION LENGTH FROM
" �/I
PUBLIC SEWER Qn $ 3.50 JD L.
HOUSE SEWER CONNECTING TO ! i� t�,�,r
PRIVATE DISPOSAL SYSTEM 1.00 �J
CONNECT ADDITIONAL BLDG. ORP. C. NO.
WORK TO HOUSE SEWER 1.00 _ CO. IMP. NO. a �/ / JOB NO.
ALTER OR REPAIR EXISTING �—
_SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT N0. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT N0.
IL
I SEPTIC TANK, SEEPAGE PIT OR '\
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL -- WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 C ES
OWNER'S PERMIT $ 1 00 CONNECTION CHARGE FE
AUTHORIZATION TOTAL FEE LI'fir REIMBURSEMENT FE
TRACTORHAVE TTOS CONNECT THE AABOVECTED WDESCTIBEDITH HE HEREXISTING DWELLING IN NdMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC.SSE
SIGNED THIS (� _DAY OF NEW HOUSE SEWER <• ,;'•,1
OWNER OR CONNECT ADDITIONAL
OWNERS AG BUILDING OR WORK
SEPTIC TANK,SEEP, PIT(S)
ADDRESS ! _ AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT i VE READ THIS APPLICATION CESSPOOL❑ DRYWELL[3AND 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 FY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED REO IRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND 1
CALIFOR IA OR T AT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBE SID TIAL PROPERTY. BACKFILL SEPTIC T;.NKS ElSEEP. PIT(S) E) CESSPOOLS
SIGNATURE
OF PER
WILLIAM J. FOX.COUNTY ENGINEER VALIDATION R. A. WOOD, CHIEF PLBG. INSPECTOR
ACO 7 2 4 v u AUG?q 4 � h,