HomeMy Public PortalAbout4903 DOREEN AVE_Sewer__ &E-02 APPLICATION FOR PERMIT 1
5&E-463 12-SE
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
WM. J. FOX,,COUNTY ENGINEER ADDRESS -
CASSATT 0. GRIFFIN, SOv'T of BUILDING CROSS ST.LOCALITY
FOR APPLICANT TO FILL IN NEAREST t
LEGAL
DESCRIPTION LOT N0. JT_1OWNER _
BLOCK TRACT / 3 6 q-s MAIL
NO. OF BLOTSADDRESS.
SIZE OF LOT NOW ON LOT CITY TEL, N0.
USE OF
BUILDINGS OISTRI CT yD. UIP 111 /4 MAP
'J'/7` H K �P
C �
CONTRACNTRAC TOR
ADDRESS J -CYONNECTION DATA
CIT TEL. N0. 9 STATION d /� J DEPTH L.
STATE l MAI FERENCE \
REGISTRATION N0. O� ❑ COUNTY / �q" 1 cS UPPER LONER S-
s TYPE_QFZ WtECTI LENGTH FROM
NO ,. DESCRIPTION OF WORK FEE Y. 4 CURB/ P.I. M.L.TO P.I.
\/ HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q $ 3.50
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR '� CO. IMP. NO. / 3e/ JOB. NO.
WORK TO HOUSE SEWER 1.00 _
ALTER OR REPAIR EXISTING / ��`
SEWER OR DISPOSAL SYSTEM TRUNK PERMIT NO. ROAD PERMIT NO. J
ANO ORO 5 ,00- TATE ENCROACHMENT
PERMIT NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL -- WASTE APPROVAL
.SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT 5 1 00 \
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
IHAVE THIS CDATEC 014TRACTEDTHE WITHC TKEOHEREIN GAOWELL N. APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOTO THE PUBLIC 5
NEW HOUSE SEWER �r
SIGNED THIS DAY F 19 n / ,
OWNER ORAIZ CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
_ SEPTIC SEEP,
ADDRESS 3 AND/ORTGRAINFIELDPiT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THI APPLICAT O CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMP
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER. REPAIR. SEWER OR 1
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ANO/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED B LOS ANGELES COUNTY AND STATE OF _ABANDON HOUSE SEWER
CALIFORNIA OR THAT THE LEGAL OWNER OF HE ABOVE �r
"DESCRIBED RESIDENT L P OPERTY. BACKFILL 5EPTIC TANKS❑ 011J{
SEEP. PIT(,) ❑ CESSPOOLS
SIGNATURE
OF PERMITTEE
WILLIAM J. FO COUNT ENGINEER VALIDATION
By
C05 7 BY`7 3 JUL 18 4 `4.5
- �. — '
DEPUTY DEP TYA
�'BY BY
y,® `�.• DEPUTY •DEPUTY