HomeMy Public PortalAbout6139 CAMELLIA AVE_Sewer__ DIEPAxTIlEfflvm OF COUNTY EN(,MM SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAF= PERMIT APPLICATION
COUNTY OF 108 ANG-ELW
WILLIAM J. FOX, CourlTY Er+oIH[ne BUILDINe a
ADDRESS a
FOR APPLICANT O FILL IN --i_iLOCATY
BUILDING % // �' NEAREST
ADDRESS /fJ ((( CRO 88 ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST / A — S
CROSS ST. E EIVED BY Rea*for InvesHO■ DATE ISSUED
OWNER ?ls/YL�C I,S/
MAIL USE tAE OCCUPANCY MAP
ADDRESS ��� 2_ Zeu M&/.25,- BK PS
CITY - TELNO.
CONTRACTOR ell, gyp-NO.
4
ADDRESS JOB N0.
CITY
TEL-NO-;�e—SZIZ TRUNK PERMIT NO.-
STATE
REGISTRATION N0. ",,= JL/)*OOUNTY ROAD PERMIT NO.
LEGAL J STATE ENCROADHMEIT
DESCRIPTION LOT NO. PERMIT NO.
BLOOK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT �(��� N WOON LOT CHARMER
CHARMER
USE �4y&4wwG
BUILDINGS DONNEOTIO SB[F[[
NO. DESCRIPTION OF WORK FE[
HOUSE SEWER CONN N HEIMBURSEM[NT FEE
PUBLIOSEWER ! 111 LBO RECEIPT 110. BY
HOIJSE IIEWEI?CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL RLDIL OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 100
ALTER OR REPAIR EXISTINAND• DAT[ BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ARAN ON S[WEQ
A;494 SPOSAL SYSTEM 1.00 CONNECTION DATA
D OR
PITS AN �DFWNFIELD Q LN STATION DEPTHOEUP5 /
RYWELL
SPECIAL CONDITIONS ONLY 2.W 7 MANHOLE RE!<ESENOE
WE
TYPE OF.CONNEOTI LENGTH FROM /
OWNERS PERMIT i I 00 MEFUh P. M.L.TO P.L
AUTHORQATION TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPEOTOR'SSIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS DAY OF Iq— NEW HOUSE SEV ER G
OWNER OR OONNECTADDITIONAL
OWNERS AGENT BUILDING DB WORK
SEPTIC TANKS SEEP.PITO
ADDRESS AND ORD RA NFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI• CESWOOL E] DBYWELL
CATION AND STATE THAT THE ABOVE 1E CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANOES AND STATE LAWS ALTEQ REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAdE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUS AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. S TAW K3
SIGNATURE S[EP.PIT(�� CESST60
OF PERU ITT
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