HomeMy Public PortalAbout9557BISBY ST_Sewer 8AK-6°' APPLICATION .FOR PERMIT
D 1
A
� iMON OF BUILDING AND SAFE7Y SEWER-SEWAGE DISPOSAL
S POSA L
Dep=rft,,.m.�nf of y of �� F.D
d
Wh4.J, FOX. COUNTY ENa1NERR
CAIIATT D.GRIFFIN,•UP'T OF■UILJ31NCI
FOR APMCANT,,Tp FILL IN NEAREST
CROSS ST. _ r
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAIL ^
ADDR f
O.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. R0.
USE OF 1,t
BUILDINGS /" DISTRICT N0. G OUP YAP
CONTRACTOR j5' y BK PG
ADDRESS I/ CONNECTION DATA 3
CITY TEL. N0. (/ STA'hON DEPTH
d� ❑ STATE MANHOLE REFERENCE
it5 W LOWER
1tGISTRATIOM 110. 7 ❑ COUNTY
TYPE RECTION LENGTH FROM f
No. DESCRIPTION OF WORK TIES T. CURB P L Y.L.TO P.L
HOUSE SEWER CONN[CTING TO
PUBLIC SEWER 3.50
HOUSE SEWER CONNECTING tO
PRIVATE DISPOSAL SYSTEM 1.00
ONN[CT
ADDITIONAL BLDG. OR
HOUSE SEWER 1.00 CO. IMP. X0. JOB. N0. LA
OkK TO
ALTER OR REPAIR 10[ISTING T
(EWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE EMCROACHYEXT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT N0.
SEPTIC T11��NK,SEEPAGE
PITS AXD/OR DRAINFIE PIT OR 2.00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
QWNEE'$ PERMT $ 1 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL. FEE 1 4yo
REIMBURSEMENT FEE
I HAVE THIS PATE CONTRACTIED. WITH THE"HEREIN NAMED Com-
TR-ACTQR TO CONNECT THEABOVE DESCRIBED EXIVING DWELLING APPEOVALS DATE INS CTOR•S SIGNATURE
TG THE PUBLIC S ER ,
SIGNED THI AY OF Ifl NEV Houa¢SEWER I 4
OWNER OR CONNECT ADDITIONAL
OWXM AG-X ffl • ti1 BUILDING OR WORK
f5:PT
C TANK, SEEP, PIT(S)
ADDRESS =.R DRAINPIELD
LOX CESSPOOL❑ DRYWELL❑
-
ANHEREBY ACKNOWLEDQE TRAT I HAVE REARTHAT THII ABOVE IS CORRECT AND AGREE O COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER, REPAIR,SEWER OR -
SEWAGE DISPOSAL SYETEY
I HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR SEWAGDISCODIS PLUG AND
LI CEN ED AS- REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIF�RRIA OR THAT I AN THE LEGAL 'QWNE:R OF TILE ABOVE
DESCRIBED 11ESIDENTIAL PROPERTY. RACXFILL C TAXKS q
a SEEP.PIT a CESSPOOla
SIGRATURE j
OF P"MITTP.E
wILu,km J.1-ox, COUNTY ENOIINmR VALIDATION
Lp&1824�R J013 4 4.50 n.
BY DT
D[PUT7 DEPUTY �[
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m DEPUTY i DEPUTY