Loading...
HomeMy Public PortalAbout6059 CAMELLIA AVE_Sewer__ D>II"A$TNM T OF UOUIgW ENUEU= SEWER-SEWAGE DISPOSAL DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION COUNTY OF LOS AN(M.>C� WILLIAM J. FOX. CouwrY F-IMINme ADUDREp I BILDING 0,j-9 ZV, C_,4 A je Z FOR APPLICANT T FILL IN LOOALITY r C BUILDING - y NEAREST ADORES{ � ORO88 T. LOCALITY "�-e_r D16TBIQT M0. Bw�for Io�e�tis■ PERMIT M0. HEAR //sJJy��i y� }� ✓ k297 -7 C CRO[8 ST, i7a'1�1 ��f�`V_f 3 J jQ RECEIVED BY DAT[ IS8IJED BY _ ATE OWNER ADDRM MAIL USE ZONE OOCUPANOY BK YAP PO CITY TEL ko. CONTRACTOR ADDRESS JOS M0. CITY ��Q TELNO. ` TRUNK PERMIT NO. REGISTRATION NO. / � STATE ROAD PERMIT M0. LEGAL E i DESCRIPTION LOT NO. O STATE ENCROACHMENT PERMIT NO. BLOCK TRACT �y `j/� INDUSTRIAL WASTE APPROVAL SIZE OF LOT—! /:V-0 NO.OF BLDOL OF M�W�IJON LOT CHARGES BUE DINGS X� �7" !//�. CONNECTION RBE FEE NO. DESCRIPTION 13F WORK FEE HOUSE SEWER CONNECTING TOREIMBURSEMENT FEE E PUBLIC SWER Q >f 248 RECEIPT NO. BY H S E ERMN ECfIm6-f0 PRIVATE DISPOSAL SYSTEM IJ/ CONNECT ADDITIONAL BLDS.0 CEPTION RECORDED WORK TO HOUSE SEWER 1.00 D b OR R PAR Ho- DAT[ BY SEWER OR DISPOSAL SYSTEM I-00 ISCONNE AND ABANDON StWER AND OR DISPOSAL SYSTEM 1.00 CONNECTION DATA SEF WE PIT R PITS AND/OR DRAINFIELD 200 STATION DEPTH r ELL SPECIAL OONDITION•ONLY Im ! HD RENC[ PPER TYPE OF OONNECTI LENGTH FROM OWNERS rT $ Y. OURG P.L M.L TO P.L. 00 AUTHORIZATION I TOTAL FEEt9RISALD/ I HAVE TH16 DATE 0ONTRACTED WrTR THE HEREIN NAMED CONTRACTOR TO CONNECT THE ABOVE DEW11JBED EXISTING APPROVALS INSPECTON'3SIGNATURE DAT[ DWELLING TO THE Pyj&LIO SEWER SIGNED THIS—Z-6—DAY OF— 19� NEW HOUSE SEWER OWNER OR r, �� BUILDING B ORECT OWORKAL owI1En ENT ADDREtS SEPTIC TANK,BEEP.PITS) AMD OR DRAIMFI[LD I HER[SY ACKNOWLEDGE THAT IHAV[ READ THIS APPLI- COMPOOL I] DRYWELL I] CATION AMD STATE THAT THE ABOVE 19 CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANOn AND STATE LAWS ALT EB REPAIFL iEWEE OR REGULATING PLUMBING AND SEWERS SEWA E D18 L iYSTE■ I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTTAO AMD/OR LIOENSED AS RE UI RED BY LOS ANG ES CO DISCONNECT PLUG AND AND STAT[ OF CALIFOR OR THAT I AM TH EGA ABANDON HOUSESEWEN ER OF THE A E D IBED [SID M AL P A SIGNATURE r iEEP.Mri(!q� CtSSF00hL - OF"PERMITTEff LIM TSAWD Sri e