HomeMy Public PortalAbout6155 CAMELLIA AVE_Sewer__ DEPA VrhUMW OF OOUNTY ENGINEER SEWER^SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
OOUNW OF 1,08 AN(EI.1C8
WILLIAM J. FOX, COuN-rY ENGINEER I BUILDING ADDRESS � q0
ADDRESS cn-Y'Cl Q ) I 1 �..
FOR APPLICANT TO FILL IN LOCALITY----T-1
BUILDING '/ ) NEAREBT
ADORESS L��j(/, �ji}�l�//�j/_�/¢ CROSS 8T.
LOCALITY �� ��Ty DISTRICT NO. SERIAL NO. PERMIT'NO.
NEAREST S A — S
CROSS ST.Z�rA�/1Sf}C�j RECEIVED BY Rsady for Iaspsstlo■ DATE ISSUED
OWNERM AIL
ADDRESS ���Q _ LST (kljs 0l , USE ZON OCCUPANCY BK YAP PG
CITY TELNO.
CONTRACTOR .
4-42,,
ADDRE8S
^} JOB N0.
�- Q J
CITY TELMO.� TRUNK PERMIT N0.
STATE
REGISTRATION NO. Jf-COUNTY ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. 7r PERMIT NO.
BLOCK TRACT INDUSTRIAL
/ WASTE APPROVAL
SIZE OF LOTaX 170 NOW ON LOT° / CHASES
USE OFu J��
BUILDINGS CONNECT HARGE FEE
NO. DESCRIPTION OF WORK FE[
HOUSE SEWER CONNECTING TO REIMBURSEMENT FE
PUBLIC SEWER 0 $ &if RECEIPT NO. D BY
HbUSE SEWER WNNEM NB 0
PRIVATE DISPOSAL SYSTEM I.M
CONNECTON S.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
AMR B PAIR EXISTIN0 NO- DAT[ BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON 8EWE2
AMD OR DISPOSAL SYSTEM 1.90 CONNECTION DATA
PITS AMD OR DBAINFIELD R 2�0 �—
STATION I-}- DEPTH
PO L—D LL
SPECIAL OONDITIONS ONLY 2.00AN BEFERENOEW�R
TYPE OF CONNECTIO LENGTH FROM
OWNERS PEILMiT $ I pp M.L TO P.L.
AUTHORIZATION TOTAL FEE
1 HAVE THISDATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS DAY OF I9_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANKK,SEEP.PIT(S)
ADDRESS AND/OR W INFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESiPOOL❑ DRYWELL
CATION AND STATE THAT THE ABOVE 18 CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STAT[ LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING'AND SEWERS. BEWAdE D18POISALSYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY IIEGISTERED
AMD/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DE30R�ED R¢SIDEI TIAL PROPERTY. TANKS
SIGNATURE / / SEEP.PIT(S)El OE88POOLS]
o
OFPERU TMp
T6A64,U "S T/63 �� ,