HomeMy Public PortalAbout5226 CAMELLIA AVE_Sewer__ `:'"�:;,,-9, APPLICA R PERMIT 1
DWIMON OF BUMDING AND SAF�'rY 5 EW ER-SEWAGE DISPOSAL
D.p�a� of county Engh--
County of Los AAgalm. enDn>NG EL
WU-J. FOX, CouNTY EMamnim
CA�ATT D.aRIP71N,SUr'T Or BUILDING LOCALrrI F / 1-� l
F
OR APPLICANT TO FILL IN NE%M F.. ^f.
cROBS ST
E E
N LOT NO. OWNER
� TRACT -3 MAIL
ADDRtlS L
N0.OF BLDGS. _
� NOW OM LOTCITY E EL. N0.
DISTRICT NO. GROUF YAF
SK PGR CONFECTION DATA
CITY -C TEL. N0. C U Y STATION DEPTH
. u ❑ STATE MAMHOLE REFERENCE
RIGISTRATION NO. ❑ COUNTY UPPER LOWER
TYPE OF CONMECTION LENGTH FROM
No. DESCRIPTION OF WORK FEE Y CURB P L. Y.L.TO P.L.
HOUSE SEWER CONNECTING TO
PUBLIC SEWER 3.30
- HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO, IRP.M0. JOB. NO.
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING
f ER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT N0.
SEPTIC TANK,SEEPAGE PIT OR
ITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY •2.00 CHARGES
CONNIZCT10M CHARGE FIR
OWNEE'S PEMUT i 1 0.0
AUTHORIZATION TOTAL FEE R[IYBURSEY[NT FSSi
I HAVE THIS-DATE CONTRACTED WITH THE H[REIM NAMED COM-
TRACTOR TO CONNECT THE ABOVE D IBED p(ISTIMG DWELLING APPROVALS DATP INSPECTOR'S SIGNATURE
TO THE PUBLIC 3 EN r�
SIGNED THI AY OF 1flsZa2 NKW HOUSE SrWKR
OWNER OR CO"ECT.ADDITIONAL
OWNERS A--EMT
BUILDING OR WORK
ADDRE ` A j C TANK,SEEP PIT(f)
AND OR DRAINFIELb
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION Cn3P0OL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGR[9 TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATI LAWS REGULATING ALTIII. REPAIR SEWER OR
PLUMBING AND SEWERS, ALTER REPAIDIMR
SEWER
R
I HEREBY CERTIFY THAT I AY PROPERLY REGISTERED AMD/OR SEWADISCONNECT FLAG AND
LICEMSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE AMD
CALIFORNIA OR THAT 1 AN THE LEGAL OWNMI OF THE ABOVE
DESCRIQ[D RESIDEMTIAL FgOPERTY. BACKFILL C TANKS❑
- f�fj� -,f • SEEP.PIT 1 Cfip"'Ll
SIGNATURE _
OF PERMrrr
WILLIAM J. FOXl A�
E%Z�
VALIDATION
;t BY 1 2'L(2 AUG 9 4 2.0O
- DEPUTY DEPUTY -
BY ■Y
DEPUTY / ' -a➢tom DEPUTT