HomeMy Public PortalAbout5341 BUTTONS AVE_Sewer__ �aS ° APPLICATION 'FOR PERMIT ]�
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
DeparLFOX.
County Engineer -
? CLos Angeles BU I LD1NG /�� � ❑
WM. JCOUNTY ENGINEERADDRESSCASSATTFIN. SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSSS ST.
LEGAL _� -
DESCRIPTION. LOT NO. OWNER
BLOCK `TRACT Z/ ? 2 ADDRESS
SIZE OF LOT.!;,Y)( 1-do NOW N0. OF BLDGS. /
ON LOT CITY TEL. NO f
USE OF
_ BUILDINGS DISTRIC�. GRyOUP .rg� MAP
CONTRACTOR /,� / T
/ CONNECTION DATA
CITY q
TEL. NO. STATI
GSL �f ��J ON 4- �� S DEPTH ,
- _ F- P
❑ STATE �-MA6 0K EFERENCE
REGISTRATION NO. 1, �. /3 " Y ` '� UPPER
/ TYPE OF CONNECTI LENGTH FROM
. No. DESCRIPTION OF WORK FEE 'r' -&Wtlr- P.L.J M.I. TO P.L. 16
HOUSE.SEWER CONNECTING TO
PUBLIC SEWER Q $ 3.50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM LDO
CONNECT ADDITIONAL BLDG. OR CO. IMP. NO.
_ WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STAT CHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK,SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- GRYWELL -- WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
PERMIT CONNEsyt N CHARGE FEE
S 1 00
OWNER'S
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER NEW HOUSE SEWERSIGNED THIS D O
J CONNECT ADDITIONAL
OWNERS gGENT
OWNER OR Ca BUILDING OR WORK
SEPTIC TANK, SEEP, PITS)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE '15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR, SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I 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 PROPERTY. BACKFILL SEPTIC TANKS❑
` ASEEP. PIT(5) ❑ CESSPOOLS El
SIGNATURE /%/A�
OF PERMI
WILLIAM J. FOX, COUNTY-ENGINEEk VAIMATION
tCo S 1 3 sAPR 16 4 4.5 0
°BT BY ....
DEPUTY DEPUTY
.
By BY {/�� ♦I/.,C
i P:® DEPUTY