HomeMy Public PortalAbout5004 DOREEN AVE_Sewer__ I
]DEPARTMENT OF COUNTY ENGENFUR I SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING
ADDRESS
FOR APPLICANT TO FILL
FILL IN LOCALITY TC
BUILDING CDQ� �O //dAEE� NEAREST L/Gs/ � CT
ADDRESS _7 CROSS ST. /\ ` ! �J
LOCALITY TEll9l�L E c iry ca�iF DISTRICT NO. A SERIAL N0. PERMIT N0.
NEAREST �` " I�� /��74
CROSS ST. �,d 1 tc .p.yJ RECEIVED
BBlf ReadY fer Inspection DATES SS/�UsED
OWNER R Ng.f2�A / Rs� e// /A /.Z/Z( /S!
MAIL �_�nJ USEZONE OCCUPANCY MAPS
ADDRESS S�>1lY t t (j/yiy BK D
CITY�-774c TELNO.
CONTRA,A',t'. O mg am O. DI�
CO.IMP.NO.
ADDRESS TEUPLF CITY, CALIF JOB.NO.
CITY TELAO. TRUNK PERMIT NO.
STATE
REGISTRATION NO. aQ 14 Z* COUNTY ROAD PERMIT NO.
LEGAL //q n ^ STATE ENCROACHMENT
DESCRIPTION LOT N0.S , `� An (�� PERMIT NO.
BLOCK TRACT /�2 ?;Q INDUSTRIAL -
•• WASTE APPROVAL
SIZE OF LOT NO.OF BLDGIL H CHARG
NOW ON LOT L•
USE D, =e' �i''z CONNECTION CHARGE FEE
BUILDINGS
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLICSEWER 0 $ 3.50 O RECEIPT NO. KATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 nD
CONNECT ADDITIONAL BLDG.OR XCEPTION REC RDED
WORK TO HOUSE SEWER 1.00 / /
ALTER OR REPAIR EXISTING /N 0- DATE IBV
S EWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR GRAINFIELD 2.00 STATION �G. �j• DEPT"
CESSPOOL—DRYWELL f
SPECIAL CONDITIONS ONLY 2.00e',,MANHOLE REFERENCE
/o/.
'el
UPPERLOWER
_ TYPE OF CTION LENGTH FROM '%AI_
00 URB -*Im.. M.L.TO P.L.
OWNERS PERMIT $ 11
AUTHORIZATION TOTAL FEE Soa
1 HAVE THIS GATE CONTRACTED WITH THE HEREIN NAMED y
�GONN- b/✓ /� Y �'iSy�J
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PlfWll SEWER
//�� / IF NEW HOUSE SEWER
SIGNED THIS...Y._9AAY OF .�_�.<.Y.____._.I
OWNER OR //+ « �/ g�5. CONNECT ADDITIONALWOR .
OWNERS AGENT. ✓ tQrW BUILDING OR WORK ,
..._....._..
SEPTIC TANK,SEEP.PIT(S)
ADDRESS......... _..j........G._'...r.__._-------------------------------------- AND/OR GRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL E] DRYWELLEl
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER. REPAIR.SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN. ABANDON HOUSE SEWER -
ER OF THE ABOVE DESCRIB ESIDENTIAL PROPERTY. BACKFILLSEPTICTANKS Q.
SIGNATURE SEEP.PIT(S)[:] CESSPOOLS
J
OF PERMITTEE..o`.j.. ..
76A642A 663 7/53 - - �-� 'i