HomeMy Public PortalAbout9026 JAYLEE DR_Sewer_9/2/1955_sewer connection 76A642D Afl I! LoaICA 11 i®N FOR PERMIT
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DIVISION OF BUILDING AND SAFM SEWER-SEWAGE ®0$fPOSA L
Deportment of County Engineer
County of Los Angeles BUILDING �$ S
WM:J. FOX. COUNTY ENGINEER ADDRESS
CASSATT D.GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL L ^
DESCRIPTION LOT N �t CI • OWNER '
BLOCK TRACT 1I)Ig MAIL IF
ADDRESS
J�NO. OF BLAS. gg i
SIZE OF LOT (/NOW ON LOT 1 CITY TEL'. N0.
USE OF
BUILDINGS • DISTRICT NO. GROUP MAP
SK PG,,
CONTRACTOR CALIF.SEWER CONST.CO. J I
ADDRESS 1317 COLEQROVE AVE. CONNECTION DATA
CITY MONTHELLO TEL. No-PA. 15048 STATION -f- M-2M �'� � DEPTHE3 STATE C �
/�Q ❑ COUNTY % �• ✓ r Ij,j ,4jUPPER REFERENCE
REGISTRATION N0. 1`YV659STATE
TYA OF CONNECT LENGTH FROM
NO. DESCRIPTION OF WORK .FEE Y. CURB PZ:; M.L.TO P.L. -
HOUSE SEWER CONNECTING TO
PUBLIC SEWER a $ 3:501
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO. IMP. NO. l`J a JOB. NO.
_ WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO. r
DISCONNECT AND ABANDON SEWER ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 STATE ENC
PERMIT NO.
e�
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL .�
SPECIAL CONDITIONS ONLY 2.00 CHARGES -
PERMIT CONNECTION CHARGE FEE f \
OWNER'S $ 1 00
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE/
TRACTORHAVE T TO CONNECT THEHIS DATE A ABOVECTED WDESCRIBEDITH THE HEREIN
EXISTING NAMED
DWELLINGAPPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC S%� - - '—
SIGNED TH1 _DAY OF 1 NEW HOUSE sewER
OWNER OR CONNECT•ADDITIONAL
OWNERS AGENT A BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESS - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND'AGREE TO COMPLY
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 DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEG L OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROP TY. BACKFILL SEPTIC TANKS❑\ , (. �'
SEEP.PIT(S1 ❑ CESSPOOLS
SIGNATURE -
OF PERMITTE •2,
WILLIAM J.,FOX. COUNTY ENGINEER VALIDATION
1..BY JkC07B4 4 ^- SEP 2 4 4.50
DEPUTY DEPUTY
�2_
BY BY
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. ® DEPUTY DEPUTY