HomeMy Public PortalAbout5327 CAMELLIA AVE_Sewer__ AMMMvT OF aOVNTY >exGMMB SEWER—SEWAGE DISPOSAL 1
IOM OF BDE.DING AND SAFETY PERMIT APPLICATION
COUNTY OF IAS ANGET
WILLIAM J. FOX, COUNTY ENCIIN[[R BUILDING 6-3
ADDRESS
FOR APPLICANT TO RLL IN LOCALITY C
BUILDING NEAREST
ADDRESS 1�3� �. �u,e GROSS ST.
LOCALITY DISTRICT NO. SERIAL M0. PERMIT M0.
NEAREST A S
CROSS ST.
RECEIV Flo �fir IMpmtls■ D E 1 ED
OWNER �,
PAIL
ADBR USE ZON OCCUPANCY AP
BK re
CITY f—I ��
60NTRAOTOR i D `�.7• pig _C. ', /,3
ADDRESS JOB.N0.
CITY TELN0. gQ, 4'Xa?�%7 TRUNK PERMIT NO.
/ �p STATE
REGISTRATION NO. ���6 -`� UJB ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. PERMIT NO.
BLOCK TRACT / 77 INDUSTRIAL
No.or WASTE APPROVAL
SIZE OF LOT Z �2d NOW ON LOT
L cm!p6m
USE OF
BUILDINGSCONNECTION CHA FEE
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
USE SEWER CONNECTING O
PUBLIC SEWER L-H RECEIPT NO. DATE BY
HOUSE SEWER CONNECTING
PRIVATE DISPOSAL SYSTEM I�0
CONNECT A I I NA BLDG-0 EXCE N RECORDED
WORK TO HOUSE SEWER I.M
ALTER 0 REPAIREXISTING N0. ATE IBY
SEWER OR DISPOSAL SYSTEM I m :!
O AND ON SEWER
ANDCONNECTION DATA
AND/OR
SYSTEM
DISPOSAL SYSTEM I.00
SEPTIC TANK,SEEPAGE P OR
PITS AND/OR DRAINFIELD 2.80 STATION Q DEPTH
CESSPO L—DRYWELL
SPECIAL CONDITIONS ONLY 2-mMANHOLE REFERENCE
.floe" LO W E R
TYPE OF CONNEOTIO LENGTH FROM
OWNERS PERMIT I L M. TO P.L. Z
AUTHORIZATION I TOTAL FEE 41 -d
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTORS SIGNATURE DATE
DWELLING TO THE PUBLIO SEWER
SIGNED THIS DAY OF Iq_ NEW HOUSE SEWER - tr-
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIO TANK.BEEP.PIT(8)
ADDRE88._. AMD OR DNA NFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL E DRYW[LL E]
CATION AND STATE THAT THE ABOVE 19 CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER.REPAIII OR
8EW[R
REGULATING PLUMBING AND BEWERL SEWAGE DISPOSAL SKR OR
I HEREBY CERTIFY THAT I AN PROPERLY REGISTERED
EIM
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT 1 AY THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIO TANKS
SEEP.PIT(8)� OE88POOL8
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