HomeMy Public PortalAbout9564BISBY ST_Sewer aCwX-at APPLICATION FOR PERMIT 1
t0=014 OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
D"-d-oza of Co—t7 Enutnew
Comm17 of Lbs Aug O" BUILDING / 1
JOHN A-LAMBIE,COUNTY ENGINEER ADDRESS C�
CABBATT D,GRIFFIN, 9ul--r OF BURDINa LOCALITY
FOR APPLICANT TO FILL IN I .
CROSS ST.
LEGAL OW N EB
DESCRIPTION LOT N0.
MAIL
BLOCK TRACT ADDRESS .
. 0 B DGS. CITY THL.K0.
SIZE F LOT ON LOT _
USE OF
BUILDINGS - DISTfiiCT X0, GROUP YAC '
BK PG
CONTRACTOR. '
ADDRESSCONM=C)lq DATA
� �y.
CITY STATION y C� DEPTH
f THL. Ko, O YAN.HOL9 RrkFim"qB k UPPER -
❑ STAT
REGISTRATION X0, ❑ COUNTY `
r
Nd. DESCRIPTION OF WORK ME
-liOUSE SRN ER con CTIXG TO TY-Pi OF CTION LENGTH 19ROM
PU8L1C SEWER a 5.66
Y. R P.L. Y.L.TO P.L.
SEPTICTAA[,SEEPA E PIT OR - -
PI AN /OR DFLAINFIELD $3.00
0 LOA E BPAGE PIT,DRAIMFIELD P. C. NO. -
EAY?L,CESSPOOL DRYWELL MANHOLE $2.00 CO, fl P. tf0. JOB N0.
OUSE Sr
ER CONNECTING TO - 1
41VAlt P AL SYSTEM @ $1.00 TRU"PEY-YIT No, ROAD PERMIT NO.
CONNECT AD ITWMAL BLDG.OR STATE ENCROACHMENT -
WORK TO HOUSE SEWER $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISP08ALSYSTEY 41.00 WASTE APPROVAL
CHARGES
l - COXNECTION CHARGE FEE -
OWN M�$ 1 00 REIMBURSEMENT FEE
AUTHORIZATION TOTAL FM
I HAVE AT THIS DATE A CONTRACT MITI] THE HERElk NAMED COX- APPROVALS DAVE INSP CTOR'SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. -m EW HOUSE SEWER
SIGNED THIS nAY OF 19- CONNECT ADDITIONAL'
OWNER OR BUILDING OR WORK -
OWNERS A69NT SEPTICTAXR,SEEP,PIT(S)
ADDRE¢S AXD/OR DRAINFIELD
• I HEREBY ACKNOWLEDGE THAT 1 HAVE READ TH13 APPLICATION CE>15FO01,ElDRY-WELL ElAND STATE THAT THE ABOVE 1E CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS'REGUt.ATINC ALTER,REPAIR,SERER OR '
PLUMBING AND SEWERS. SEWAGE DI/POS LSYSTEM
I HEREBY CERTIFY THAT I Ali PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LI CENSFD AS.REQUIRED �Y LOS ANGELES COUNTY AND STATE OF ,�,gANDO HOUSE SEW ER
CALIFORNIA OR THAT 1 AY THE EGA{. OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE ESP.PIT(S) ❑ CESSPOOLS
OF PERMI
JOHN A. LAMBIE, COUNTY ENGINEER Y Tn T^ATION� ROBERT A. WOOS, CHIS:F PLIOG. INr15PSCTOR
Ci. Y.-0. .
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