HomeMy Public PortalAbout6013 CAMELLIA AVE_Sewer__ 'DEP"' NT OF COUNTY Eve
DSEWER—SEWAGE DISPOSAL 1
' M3ION OF BIIII.DING AND SAFETY PERMIT APPLICATION
0OTNTY OF LOS ANGEL BUILDING
WILLIAM J. FOX, COUNTY ENOIH[[R I ADDRESS
FOR APPLICANT TO HLL N �[ LocALITY
ADOREBUILD6�f3 �QTj7a Q�'� ST NEAREST
1,4
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CROSS ST
LOCALITY T DISTRICT NO. SERIAL NO. PERMIT NO.
aRO,�e- las �� s
A 3 �� s
f /� HEO IVE�BY Ru[q�for Ioop�atioi RATE I�SySU D
OWNER �C K�-t l� /✓ — Li
PAIL 1 EZONE OCCUPANCY MAP
ADDRESS J� �� BK P9
CITY J/ TKLM(L L I
CONTRACTOR ' O
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ADDRESS f V ✓. b. JOB NO.
CITYS TELNO T TRUNK PERMIT N0.
C 7 / G ` STATE
REGISTRATION M0. 7 � b '❑ COUNTY ROAD PERMIT N0. C)
LEGAL
DESCRIPTION LOT NO. Q ,[,� STBYET NOROACHMENT
PEIBLOOK TRACT �'$`�, INDUSTRIAL
ASTE APPROVAL
SIZH OF LOT NO.OF BLDGS /
OW ON LOT CHARGES
USE OF
BUILDINGS Q OONMEOTIO RGE REE
M0. DEBCRIPTLON OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUB LIOSEWER Sze HEOEIPTNO. TE BY
HOUSE 85WER CONNECTING Yo
PRIVATE DISPOSAL SYSTEM Im
MM 0 A ION BL &001 EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00 Y0
AL OR PAI .IST MB DATE BY
SEWER OR DISPOSAL SYSTEM I.W
DISODMIdEOrr ANb ABANDON SEWER
AMD OR DISPOSAL SYSTEM 1.90 CONNECTION DATA
ANK.SEEPAGE PIT
PITS AND/OR DRAINFIELD B 2XISTATION DEPTH
cUMOOL--bRYWILL
BPEGIAL 00MDITIONS ONLY 2.50 / MHO E REFERENCE E
fV
TYPE OF CONNECT 0 LENGTH FROM
OWNERS PERMIT $ 1 00 Y. CURB L M.L.TO P.L
23
AUTHORIZATION TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
OONTRACTOR TO CONNECT THE ABOVI DESORIBED EXISTIMQ APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING HE FUBLJO SEWER
SIGNED THI DAY OF 19— NEW HOUSE SEWER Q
OWNER OR CONNECT ADDITIONAL
OWNERS AGE BUILDING OR WORK
SEPTIC TANK'SEEP.PIT(S)
ADDRESS AND/OR GRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL I] DRYWELL E]
CA
TIONAMD STATE THAT THE ABOVE 16 OORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINAYOES AND STATE LAWS ALTER,REPAIR,BEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY OERTIFY AT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND LICENSED QUIRED BY LOS ANGEL UNTY ABANDON HOUSE BrWER
E
AND STATE OF flMIA OR THAT I AM THE L OWN.
ER OF THE ABO IBSD HESID[MTIAL P P AM []
BEEP.PIT(g)❑ CESSPOOLS❑
SIGNATURE6e l
OF PERMITTIE ir
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