HomeMy Public PortalAbout5333 CAMELLIA AVE_Sewer__ I
T)F:PAIMM'iT OF OOU= ENGEM R SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUELDING AND SAFETY PERMIT APPLICATION
COUNTY OF 1.08 ANGFT.lrli
WILLIAM J. FOX, COLIHTY ENOIN[[R BUILDING
AUILDIN 1►1„'
FOR APPLICANT TO RLL IN LOCALITY `r C
BUILDINGNEA
ADDRESS • CROSS ST.
LOCALITY DISTRICT NO. SERIAL M0. PERMIT NO.
NEAREST A 52g S
CRO88 ST. ECEIVED BY Rc�fw InspeeUes DATE ISSUED
OWNER
AIL
ADDRESS �J G 7 US¢20 OOCUPAMDY BK MAP re
�1
CITY t Ti R0. r
CONTRACTOR
ADDRESS
JOR.M0. 1
4
CITY fir" r TEL110. 0 r TRUNK PERMIT NO.
REGISTRATION N0. e C e STATE
ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. PERMIT NO.
BLOCK TRACT ? 7�� INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT N0.OF 8LD88
NOW ON LOT CHARGES
USE OF
BUILDINGS CONNECTIO E FEE
NO. DESCRIPTION OF WORK FE[
HOUR 8 ER CONNE N 0 REIMBURSEMENT FEE
PUBLIC SEWER 0 4 a-" RECEIPT NO. D BY
HOUSE SEWER 0ONN CTING TO
PRIVATE DISPOSAL SYSTEM I.00
NN A ION B OR EXCEPTION RECORDED
WORK TO HOUSE SEWER I.H
ALTER OR REPAIR 1 NO NO' DATE BY
SEWER OR DISPOSAL SYSTEM I"
DISCONNECT AND ABANDON SEWER
AMD OR DISPOSAL SYSTEM IAB CONNECTION DATA
EPTIO TANK,SEEPA —PI'F fl
PITS AND OR DRAINFIELD I.M STATION DEPTH
OESS Po"
SPECIAL OONDITIONS ONLY !.N / MA pE EFERENCE
TYPE OF CONNE!J P LENGTH FROM
Y.L.TO P.L -v
OWNERS PERM $ 1 00
AUTHORIZATION TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRAOTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS I NSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS DAY OF Iq_ NEW HOUSE SEWER S- S
OWNER OR DONNECT ADDITIONAL
OWMERB AGENT BUILDING OR WORK
SEPTIC TANK(BEEP.PIT(S)
ADDRESS AND/OR DHA NFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPL1• CESSPOOL[] DBYWELL
CATIONAND STATE THAT THE ABOVE 18 00RRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER.REPAIR,SEWER OR
REGULATINGPLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY OERTIFY THAT I AM PROPERLY REGISTERED
AMD/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISWNNEOT PLUG AND
AND STATE OF CALIFORNIA OR THAT I AN THE LEGAL OWN- ABANDON HOUSESEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. RADKFILLSEPTIO TANKS[]
SIGNATURE '�� G _ _(/ � � SEEP.PIT(S)� CESBPOOL60
OF PERMITTEE l �-�+^O'f �` —41
TOAD4SA 8M T/68 / l