HomeMy Public PortalAbout6053 CAMELLIA AVE_Sewer__ DIEPAsTNEENr OF COUNTY ENGI3 SEINER—SEWAGE DISPOSAL 1
DlIrBION--OF B=ING AND SAFETY ' PERMIT APPLICATION
COUNTY OF IAS ANGEI
WILLIAM J. FO . COUNTY F�10INCER BUILDING
X
ADDRESS � v
FOR APPLI TO FILL IN '-00ALJTM
BUILDING NEAREST
ADDRESS CRO
S
S
ST.
LOCALI DISTRICT III Raaf for IwpKtloo PERMIT M0. C
MEAREST �� 3 5
�(04'�
CROSS ST. NPe7lllf
_ p REC IVED B DATE ISSUED DATE
OWNER , /T C/7d/17 D �/ `s
MAIL
ADDRESS SSE ZQK OOCUPAMOY SK YAP rQ
�/
//�.�'• L/TELMO. C/�1CJ
OONTRACTO -OLT�3Ah:4,r JG717. L P• 00.INR M0. 1.3 Q ^
ADDRE�So� /11•x/7///IZ JOB.NO.
0117 n- n/a � � TEL MO- TRUNK PERMIT NO.
REGISTRATION NO. �J�Jn� 0 ITN ROAD PERMIT NO. Z e
LEGALSTATEENCROAONYEMT
DESCRIPTION LOT NO. -1-6-Al / PERMIT NO.
■LOOK TRACT INDUSTRIAL
_ WASTE APPROVAL
SIZE OF LOT S D ,Y NOW ON LOT'- CHARGES
USE OF
BUILDINGS E/ •1� CONN N CHARGE FEE
NO. DESCRIPTION OF WORK FEE HO
US6 ER COON E M TO REIMBURSEMENT
PUBLIC SEWER * Il S-50 RECEIPT NO. BY
HOUSE SEWER CONNECTING
PRIVATE DISPOSAL SYSTEM IJM
Zf Ni'-N ADDITIONAL G OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.08
ALTER O�EPKTR EAISTIMB MG- DATE BY
SEWER OR DISPOSAL SYSTEM IAO
I�SCONNECT AND ABANDON 61CWtIt
AND OR DISPOSAL SYSTEM I" CONNECTION DATA
- S PTIC AM ,SEEPAGE PIT OR 4- 31
PITS AND/OR=INFIELD 2-00 STATION . DEPTH
CESSPOOL—D ELL
SPECIAL CONDITIONS ONLY 2-00 MA PPEQ FERENOE
/
TYPE OF ONN[CT LENGTH FROM
OWNERS PERMIT I 00 Y. CURB PL
Y.L.TO P.L
ALM-10 ATION TOTAL FEE o
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESORIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEINER
SIGNED THI Yi0 14`-' NEW HOUSE&EINESlW"E A
CONNECTADDITIOMAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TAMS(,SEEP.PIT(&)
ADDRESSJ6, AMD/OR DRAINFIELD
I HEREBY OWLEDGE THAT I HAVE READ THIS APP - CESSPOOL E] DRYWELL
CATION AND STATE THAT THE ABOVE IS ORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIRR,SEWER OR
REGULATING PLUMBING AND SEWERS SEIYABE DI&P L SYSTEM
I HEBEBY CERTIFY THAT I AM PROPERLY REGISTERED
AMD/OR LICENSED AS REQUIRED BY LOS ANGELES OUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT 1 AN THE LEGAL OWN- ABANDON HOUSE SEINER
ER OF THE ABOVEBED M PBOPF_IZIY.
fEEP.PITME] CESSPOO
SIGNATURE
OF PERYITTE
TEASUD R&M 063 4/64