HomeMy Public PortalAbout5806 CAMELLIA AVE_Sewer__ ..;�,. APPLICATION FOR PERMIT
_ DIVISIOONO.,F..,BMLDING AND SAFETY SEWER—SEWAGE DISPOSAL
BUILDING
yl WJ. FOX.COUKTm
Y=NOiNI ADDRESS
M.
CLAO"TT D.dRnrnN.SUIP-r or MUEWn" LOCALITY
FOR APCANT TO FILL IN N EAR EST
LEGAL
DESCRIPTION LOT -rd OwXER
BLOCK TRACT ADDRESS Q J
X0. OF BLCITY TML- NO �J
SIZE OF LOT XQW ON LOTOT
USE OF l
BUILPINGS ( - DISTRICT NO. GROUP YAP
BIC FG
CONTRACTOR L -, Z-
ADDRESS -•� � ,
t COMMMON DATA
1 CITY ) .. TEL- N0. M,- STATION DEPTH 0 '
��++ ❑
STATE MANHOLE REFERENCE UPPER
REGISTRATION No. l�r��^
No. DESCRIPTION OF WORK FEE
TYPE OF CONNECTI LENGTH FROM J
HOUSE SEWER CONNECTING TO T CURB .L Y L. TO F L.
PUBLIC SEWER 3.50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG,OR P. C, N0.
WORK TO HOUSE SEWER 1.00 CO EYP N0. 7g4JOB NO.
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT XO. ROAD PERMIT NO.
DIf ONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK,SEEPAGE PIT ORINDUSTRIAL
PITS AND/OR DRAINFIELD •� WASTE PROM
CESSPOOL-DRYW ELL
SPECIAL CON-DITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FE¢
OWNEE S PENIN s 1 00
lI=O=ATION I TOTAL fa REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN MAIMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED "ISTING DWELLING AMOVALS DATE lN8 'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THI 19^ NEW HOUSE SEWER
CONECT
OWNER OR BUILDING OR WORKAL
OWNERS AGE
SEPTIC TANK,SEEP,PITS)
ADDRESS AND/6R DRAIXFIELD
1 HEREBY A LED THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL[IAID STATE THAT THE A OVIE V CORRECT AND AgRSE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAfq,SEWER OR
PLUMBING AND SEWERS. "AGE DISPOSAL SYSTEM
1 HERESY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY ANGELES AND STATE OF DISCONNECT PLUG AND
CALIFORNIA ON THAT GAL M OF THIL AROY ABANDON HOUSE SEWER
DESCRIBED RESID FRO BACEFILL S C TAN"
� SEEP.PIT 8 CFJSSPOO
SIGNATURE
lgx
OF PER
J.F X.CoLumr ENGlumml VALMAT ON R.A.WOOD,CHtor Pu G4 tNsP cToPt
:}��0 8 1 1 r FA.Y 14 4 4.5 0 n