HomeMy Public PortalAbout10633 OLIVE ST_Sewer_11/25/2003_18676S HOUSE SEWER CONNECTION TO PUBLIC SEWER DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING NEAREST
ADdR£SS _ CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST ------ A S
CROSS ST.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL —�
ADDRESSUSE ZONE OCCUPANCY MAP
--------------__ I BK PG
CITY TEL.NO.
CONTRACTOR
ADDRESS
CITY T£L.NO. TRUNK PERMIT NO.
STATE -
REGISTRATION N0. .COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF BLDGS.
NOW ON LOT CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK. FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER _ @ 1113.50 RECEIPT NO. DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO. DATE BY
SEWER OR DISPOSAL SYSTEM 1.00 i
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 { CONNECTION DATA
SEPTIC TANK,__ SEEMGE PIT OR
PITS AND_/OR DRAINFIELD 2.00 1 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY
— I _ w MANHOLE REFERENCE
'UPR
ci
TYPE OF CONNECTION LENGTH FROM
Y. CURB P.L. M.L.TO P.L.
OWNERS PERMIT $ I 1 00
AUTHORIZATION I TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS.......a.....,....---DAY OF..... ..............................19........ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT._-..--.:.: BUILDING OR WORK
.
._................................- ......__... - ----------
SEPTIC TANK,SEEP.PIT(S)
ADDRESS- .......... --- ---------------------___......----------------------._ AND/ORDRAINFIELD i
! HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLI. CESSPOOL[] DRYWELL
CATICN AND STATE THAT THE ABOVE IS CORRECT AND AGREE _
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER i
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC'TANKS
SIGNATURE SEEP.PIT(S)n CESSPOOLS
OF PERMITTEE:` ----- ----- .......................-
1
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