HomeMy Public PortalAbout4829 CAMELLIA AVE_Sewer__ DEPARTMENT OF COUNTY ENGENEER SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
' COUNTY OF LOS ANGELES
WILLIAM J. FOX. COUNTY ENGINEER BUILDING
ADDRESS r
FOR APPLIrYANT TO FILL IN LOCALITY 1 rA_AM
BUILDINGNEAREST
ADDRESS " Alm
qq d�ui 'Lj CROSS ST.
LOCALITY I�� CL.A�>• DIST4R IJT�N O. SERIAL NO. PERMIT`NO.
NEAREST / y/ �✓1 I V A �L / /O �t� S
CROSS ST,
RECEIVED BY R..dY for ImpeoUon DATE ISSUED _
MAIL
ADDRESS 454k 06USEZONE OCCUPANCY BK MAP PG
LLLL
CITY^ F� TIO 9 6 X
CONTRACTOR L� Pj� GC- f' �j�/�' CO.IMP.NO.
ADDRESS �2 C '13 ny', JVD ` /•
�+ JOB.NO. SJ � v
CITYJ�, TTEL 140P t,/ (�i?❑7 x TRUNK PERMIT NO.
REGISTRATION N0. y`% ��( /� �•% Y[] STATE
COUNTY ROAD PERMIT NO.
LEGAL •� STATE ENCROACHMENT
DESCRIPTION LOT N0. / r2 PERMIT NO.
BLOCK TRACT \J �( (� ( INDUSTRIAL_VASTAPPROVAL
SIZE OF LOT `` 0�,, /T NO.OF BLDGS.
(Q{/.�( 1 7 r� NOW ON LOT � CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE - REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
P.
BLIC SEWER @ $ 3.50 RECEIPT NO. I DATE IBY
N OUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER IAO NO. DATE IBY
ALTER OR.REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
ANO/OR DISPOSAL SYSTEM I.00 CONNECTION DATA
SEPTIC TANK.SEEPAGE PIT OR �+
PITS AND/OR GRAINFIELD 2.00 STATION 2 Z. J ' DEPTH G /
SPECIAL CONDITIONS ONLY 2.001 IMAN LeacRE FERENC�� LOWER
TYPE OF CONNECTION LENGTH FROM
Y. cCURQ P-L.— ( M.L.TO P.L.
OWNERS PERMIT = II 00
AUTHORIZATION I TOTAL FEE (y (STI
1 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 THISJ.`....qDAY . . .. ..........._.19-4-1 NEW HOUSE SEWEROWNER OR CONNECT ADDITIONAL
OWNERS {A�G�EpN�T.: _ .. _ _.. ._._._._ BUILDING OR WORK
ADDRESS_:.jq..'. . .... .... ..... AND/OR GRAINFIELD EPTIC TANK.SEEP,PIT(S)
Q C
iHEREBY ACKNOWLEDGE HAT 1 NAVE READ THIS APPLI- CESSPOOL[-] DRYWELL[]
CATIONAND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITHALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY/JTHAT 1 AM PROPERLY REGISTERED DISCONNECT NECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY
APID STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTICTANKS�
SEEP-PIT(S)C] CESSPOOLS
SIGNATURE /�,�.(
OF PERMITTEE..._ ...–......._..`-�"�:..—...._.........._......_.........._.
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