HomeMy Public PortalAbout5120 DALEVIEW AVE_Sewer__ .'78AE-66 APPLICATION. FOR PERMIT
`Be88DMSION OF BUMDRVG AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of a BUILDINADDRESSG IV 6_�
WM. J. FOX, COUNTY
EN ENGINEER
CAOEATT D. GRIFFIN. Suri OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS sr+
LEGAL
DESCRIPTION LOT NO. Z
`, OWNER d/ ,As•y�.�..���sY/.///_}}((✓�
BLOCK TRACT J 7 e a a MAID•
.A O D REBS
NO. OF BLDGS:
SIZE OF LOT 0 [NOW ON LOT CITY TEL NO. _
USE
BUILDINGS fJj%/�Q//�}.l// DISTRICT NO. GROUP MAP
BK PG
CONTRACTOR .+Fi1f/� �/�w M J
" ADDRESS ,.�� a� ��iCONNECTION DATA
CITY N, / TEL. N0. 1t, STATION DEPTH r /
q n
REGISTRATION NO, ✓ ❑ COUNTY _, D;Zr 3'S I NHOLE REFERENCE
UPPER :L.pBSA
TYPE OF CONNE IOJ/.ti LENGH FROM
NO. DESCRIPTION OF WORK FEE Y. CURB
/I' L.I M.L. TTO P.L.
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ S 3.50 Q
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO. IMP. N0. /� S JOB._N0.
_ WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT N0.
SEPTIC TANK,SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHAR
OWNER'S PERMIT CONNECTION CHARGE FEE
E 1 00
AUTHORIZATION TOTAL FEE 50 REIMBURSEMENT FEE
-
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE.ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC.SEWER -
SIGNED THIS DAY OF - 79 NEW HOUSE SEWER
OWNER OR - - CONNECT ADDITIONAL -
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK. SEEP, PITS)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ 'DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR -
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
ABANDON HOUSE SEWER
CALIFORNIA 'OR THAT. I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. a
BACKFILL SEPTIC TANKS
SEEP. PIT(S) ❑ CESBPOO❑LB1� Ld
SIGNATURE
OF PERMITTEE
WILLIAM J. FOX, COUNTY ENGINEER v VALIDATION .
By - -i..�o02'1:1512^ KOV22 4 450 tD
DEPUTY DEPUTY
BY BY
f ® DEPUTY DEPUTE �,'