HomeMy Public PortalAbout10018 LA ROSA DR_Sewer_12/17/1953_19531-S sewer connection DFFARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGFJ S
WILLIAM J. FOX, COUNTY ENGINEER II BUILDING
ADDRESS 1(n(7) 1 Y1
a� ` 11QP
FOR APPLICANT TO FILL IN LOCALITY-----Tr-j _
BUILDING A/ NEAREST
ADDRESS Q �.�li /��U�7�/ CR088ST. �"'� f _LA
LOCALITY / j (J�Q (/ / - DISTRICT N0. SERIAL N0. PERMIT N0.
CNEAREST
ROSS ST. / 4p `
ECEIV ED BY Ready tar Inrneetlen GATE ISSUED
OWNER e $, 'Z-1 Q
MAIL
ADDRESS� - -o"//l�Z/ USE ZONE OCCUPANCY BK MAP PG
A'O/N
CITU TEL.NO.
CONTRACTOR .� �^ CO.IMP.NO. �Z
ADDRESS
JOB N0. -----------
CITY TEL.NO. TRUNK PERMIT NO.
6TATE —�
REGISTRATION NO. ® COUNTY ROAD PERMIT NO.
LEGAL / ry
DESCRIPTION LOT NO./qA (rJ I eY° IF STATE E NO ROACHMENT
n a PERMIT N0. �^
BLOCK /� TRACT > / INDUSTRIAL
/ / WASTE APPROVAL
SIZE OF LOT X [7 � ' NOW ON LOTS / CHARGES
USE OF .J1 � n'
BUILDINGS TT X CONNE6T10f/.G 11_ARGE FEE
NO. DESCRIPTION OF WORK FEE /
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER 4 3.50 RECEIPT N0. I DATE BY
PHOUSE SEWER CONNECTING TO
PRIV ATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR (EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00 xJ
ALTER OR REPAIR EXISTING / NO' I DATE IBY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 /�` CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS PND/OR GRAINFIELD 2.00 STATION _ DEPTH
CESSPOOL=DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
_'UPPER '%, LOWER
TYPE•OFCONNECTION LENGTH FROM
OWNERS PERMIT = 1 00 CURB I P.L. M.L.TO P.L.
AUTHORIZATION TOTAL FEE Z. Oc Oj .141 n r\,q !
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED .
CONTRACTOR TO CONNECT THE ABOVE DESCRIBEDEXISTING 'APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS------
�_..! DAY OF...... �� ' 19 5v NEW HOUSESEWER
OWNER OR GOOWNERS AGENT....p n�7eM�-':,.^^....rJ!Y.l_.. .L_- (�!. .�....� _gB�UNLOENG OR WORK
AL
ADDRESS TIP..C.._..!!.`i[�'.tO_-^_AOJ..- _C...df..4KF —AND/OPTICR GRAINFIELD PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI• CESSPOOL E] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE I
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 HOUSESAND
ANO STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS E
[ SEEP.PIT(S)El CESSPOOLS E]
SIGNATURE I��� �/ '
OF PERMITTEE..._ _.�... 1._.........._.._.._... .
TOA642D 663 1/53
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