HomeMy Public PortalAbout9072ACASO DR_Sewer DEPAR MENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
,�. COUNTY OF LOS ANGELES 'y'
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS ��� ;Ll
FOR APPLICANT FILL INQU610 ' LOCALITY
BUILDINGNEAREST
ADDRESS CROSS ST
LOCALITYi � c71T-/ DIISSTRICT NO 0 SERIAL NO PERMIT NO c
NEAREST (°J A � 3-9 2— `'�F6r7 J
CROSS ST J
RECE Ready for Inspection DATEISSUEO
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OWNER !/
ADDRESS MAIL �[- e/ C��� C ��
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CONTRACTOR R�r"y 4) �\C TI-41
- -CO.IMP NO -7
ADDRESS t' C��}/4-4— JOB NO
CITY Aee, 0 ; I ` TEL NO P0J j3J� TRUNK PERMIT NO
REGISTRATION NO //y V �� STATE ROAD PERMIT NO
LEGAL f7 JL l„• � y
DESCRIPTION LOT NO � J'1
1 G� / , J �L/ STATE
ppROACHMENT t
BLOCK TRACT _(( lY•�d 9j_ + I ;L•.� '�� INDUSTRIAL
I WASTE APPROVAL
SIZE OF LOT 3*0 X NO OF BLDGS
&A'O NOW ON LOT d CHARkES /
USE OF
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BUtLOIDIRGB vi Cl 141,4• CONNECTION CHARGE FEE v
NO DESCRIPTION OF WORK FEE \
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•
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
_ (.S
PUBLICSEWER a $ sic
RECEIPT NO DATE \ BY
r
PRIVATE TEEDISPOSAL STNG EMWER TO 100 �Il
CONNECT ADDITIONAL BLDG OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1 00
ALTER 6R REPAIR EXISTING / NO I DATE 113Y
SEWER OR DISPOSAL SYSTEM foe ; �O
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK SEEPAGE PIT OR L
PITS AND/OR DRAINFIELD 2 00STATION 3 �� DEPTH
CESSPOOL—DRYWELL 1
SPECIAL CONDITIONS ONLY 200 f ' MANHOLE UPPER EFERENCE Z �
TYPE OF CONNECTION LENGTH FRO
OWNERS PERMIT ; I 00 i CURB -P L.- ML TO P Ly
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THE PUBLIC SEWERq G APPROVALS INSPECTOR'S SIGNATURE DATE
SIGNED THIS DAY OF �`�"�=_ ___.19_� .• NEW HO a S�R (j
OWNER OR CONNECT ADDITIONAL " G
OWNERS AGENT - ..� _. _ BUILDING OR WORK
ADDRESS - - - AND/OR DRAIPIT(S)
NF ELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ HIS APPLI- CESSPOOL❑ DRYWELL E]
CATION AND STATE THAT THE ABOVE IS COB
AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES A STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR-LICENSED AS REQUIRED BY LOS ANGELES COUNTY
AND STATEOF CAL NIA OR THAT I AMT E LEGAL OWN- A ANDON HOUSE SEWER
ER OF THE ABO E RIBED RE DENTI OPER Y CKFILL SEPTIC TANKS
SIGNATURE EEP PIT(S) CESSPOOLS❑
OF PERMITTEE
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