HomeMy Public PortalAbout5760ALESSANDRO AVE_Sewer D
6aE 683 12 S4 Irl •APPLICION FOR■ ■ Ee \MIT 1
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DIVISION OF BUILDING AND SAFETY SEW -!!!SEWAG E_D I SPOSAL._
Department of County Engmeer
County of Los Angeles, BUILDING
ADDRESS
WM J FOX COUNTY ENGINEER
CASSATT D GRIFFIN SUP T OF BUILDING LOCALITYj7
FOR APPLICANT TO FILL IN NEAREST
LEGAL
.ry CROSS ST
DESCRIPTION'f- LOT N,A/ OWNER
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BLOCK TRACT y� S't/ / MAIL
ADDRESS V J�
NO
SIZE OF LOT/` x / g-6— NOWOONBLOTS CITY }a C.��✓`�� EL NO _ G
USE OF
BUILDINGSN DISTRICT NO GR blUP MAP
CONTRACTOR �.�� I BK I / PG
ADDRESS rrs CONNECTION DATA
CITY �.. h TEL NO �. G{' D STATION 1/'Z,!X DEPTH
/ ❑ STATE d MANHOLE REFERENCE
REGISTRATION NO / y / ❑ COUNTY L= 4 _,1LOWER
TYPE OF CONNECTION LENGTH FROM G
NO DESCRIPTION OF WORK FEE =10-- CURB _GrI:_ / M L TO P L
HOUSE SEWER CONNECTING TO
� �/`3.T C-)
_ PUBLIC SEWER Q $ 3 50
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR CO IMP NO / JOB NO
_ WORK TO HOUSE SEWER 1 00ALTER OR REPAIR
a
_ SEWER OR DISPOSAL S SITEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
OWNERS I pEItMIT $ 1 [-DO
AUTHORIZATION I TOTAL FEE REI ABURSEMENT FEE
TRACTORHAVE TTO CONNE THIS DATE OTHEAABOVE DESCRIBED EXISTINGCTED WITH THE HEREIN ADWELLING CON APPROVALS DATE INSPECTOR S SIGNATURE
TO THLE fUBLIG-SERER
t� I / /; rte NEW HOUSE SEWER - 5� �Af1L1�. j
SIGNED TR( f DAY OF� _ 19� �+—
OWNER ,y�rJ CONNECT ADDITIONAL
OWNERS `R`PEN �J�' �' BUILDING OR WORK
SEP
ADDPESS�1 �.�11�ilil.a AND/TORT RANK AINFEELDPIi(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL[IDRYWELL[IAND 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
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT i AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL P OPERTY BACKFILL SEPTIC TANKS 11SEEP PIT(S) ❑ CCSSPOOLS
ti.
SIGNATURE V_
OF PERMITTEE
WILLIAM J FO COUNTY ENGINEER VALIDATION `
0 G2257APR 5 4 f u 50 to
'BY BY .- _
DEPUTY 1 DEPUTY„
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BY BY
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