HomeMy Public PortalAbout4843 DOREEN AVE_Sewer__ ` E6° APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer j/ p'JJ
Countp of Los Angeles ADULDIt
DRESS Ll 73 N• DQj'e.C'h ST
_ WM. J. FOX, COUNTY ENGINEER
CASSATT D. GRIFFIN. SUP'r°P.Sw LDING' iocu }'prY T?wrr nl� C+ I
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FOR APPLICANT TO FILL IN NEAREST /I� nrr
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CROSS ST.
LEG
DE CRIPTION LOT NO. Per��l Z-W e, ]O PI 79I
BLOCK TRACT /36l_/S_ MAILADORESs
��"IJ AI♦ Y`.O.��G� ��
N0.OF BLDGS. / �l '7 I,J `I✓
SI2E OF LOT S45 X /70 NOW ON LOT' / /Y l+
(( CITY. Q1N 1 \ TEL. NO. ,
ll
BUILDINGS DfL'C/(11rO
{ ` DISTRICT NO. GROUP MAP
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CONTRACTOR �Q W JY� / %'e r-YI•E\� T �� /�
ADDRESS A 3 j `-'rj1 Y Q YOv �,y.pA ••%% CONNECTION DATA
CITY Aa.t jj•VitN ACf.k TEL. NO.erl 73 j9�j(' ISTATIO DEPTH
3 3 9110 , p BTATE — MANHOLE REFERENCE
REGISTRATION NO. ❑ COUNTY UPPER LOVIEP
TYPE CF'CO ! 'CTION LENGTH FROM
,NO. ..DESCRIPTION OF WORK FEE Y. CURB P.L. M.L.TO P.L.'
1*1
•HOUSE SEWER CONNECTING TO
,PUBLICSEWER ' @) S 3.S0 _
HOUSE SEWER CONNECTING TO
_ .PRIVATE DISPOSAL SYSTEM 1.00
,CONNECT ADDITIONAL BLDG. OR
WORK TO HOUSE.SEWER 1.00 J &110 CO. IMP. N0. NO.
ALTER OR REPAIR EXISTING
'SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT N0. 7 l0e,
ROAD PERMIT N .
'DISCONNECT AND ABANDON SEWER STATE ENCROACHAIENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO,
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL -- WASTE APPROVA
SPECIAL CONDITIONS ONLY 2.00 CHARGES
PERbIIT CONNECTION CHARGE FEE
OWNER'S $ 1 00 i
AUTHORIZATION TOTAL FEE Do REIMBURSEMENT FEE
TRACTORHIS TO CONNECT THE ABOVEITH THE HEREIN DESCRIBED EXISTING OWELL NG APPROVALS DATE INSPECTOR'S.SIGNATURE
TO THE PUBLIC'SEWE
SIGNED THIS�DAY OF �e-h CuAY_T_19i1J NEW HOUSE SEWER
CONNECT'ADDITIONAL -
OWNER" OR -
OWNERS AGENT BUILDING OR WORK jSf
SEPTIC TANK,SEEP, PITS)
ADDRESS - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS'RPPLI CATION CESSPOOL❑ DRYWELL❑ _
AND STATE THAT THE. ABOVE IS CORRECT�AND AGREE TO-COMPLY -- '
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER, REPAIR,SEWER OR _
I HEREBY CERTIFY THAT 1 AM..PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM.
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT.-1 AM THELEGAL OWNER OF THE 'ABOVE' ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY.- BACKFILL SEPTIC TANKS[I
SEEP. PIT($) 0-CESSPOOLS❑
SIGNATURE
OF PERMITTEE' _ - • - /I�/
WILLIAM J:FOX,,COUNTY-ENGINEER VALIDATION
_ Oy3-3 2n FEB 8 4 2.0-0
i 87
. DEPUTY .^--DEPUTY
BY
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