HomeMy Public PortalAbout5005 DOREEN AVE_Sewer__ DEPAR'PMWNT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING SDO. -
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY 'T'C,T
BUILDING ��O _ `• •� C1 NEAREST 1/ ///
ADDRESSS /J�/^�� ✓/ CROSSST. /� �/ (/GCS r�
NEAREST
LOCALITY �P -" DISTRICTA SERIAL N0. PERMIT N% C
CRo$S ST. /C eU l� J ✓ J
- J l/JRE/CEI�VED.BVfyjReeOfor lneeton AtEUE
OWNER R2Se
MAIL �d� �r��'yl
ADDRESS f/� USE ZONES OCCUPANCY
BK PG
CITY �E /_JG'�TELAO. ��/ / 3 -7
CONTRACTOR ,� -� / �' Off,
�) f� CO.IMP.N0.
ADDRESS ��,��iliC 1711 JOB NO.
CITY/� ' �C� TE))L.NO.6� .11dlo TRUNK PERMIT NO. /
REGISTRATION NO. �9n� STATE
� COUNTY ROAD PERMIT NO.
LEGALSTATE ENCROACHMENT '
DESCRIPTION LOT N0, �3mvIGU. /O,?. / PERMIT N0.
BLOCK TRACT /�` q� BYC�Pr INDUSTRIAL
�NO,OF BLDG$. WASTE APPROVAL
SIZE OF LOT NOW ON LOT CHARG S
USE OF
BUILDINGS �,J/�ef�C'� CONNECTION CHARG FEE
NO. DESCRIPTION OF WORK FEE
H OUSE SEWER CONNECTING TO REIMBURSEMENT FEE
/ PUBLIC SEW ER 0 S 3.50 3 .�Q RECEIPT NO. DATE IBY
HOUSE SEWER CONN ECTI NG TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTEFFOR-SEWER OR DIDISPOSALSYSTEMSYSTEM 1.00 / DAT\ BY
I
DISCONNECT AND ABANDON SEWER ,
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR /
PITS AND/OR DRAINFIELD 2.00 STATION 7//7, 7 DEPTH
CESSPOOL—DRYWELL
S P ECTAL CONDITIONS ONLY 2.00 71,e MANHOLE REFERENCE
� WER
!( LO )
TYPE OF CON@�I__ECTION LENGTH FROM
OWNERS PERMIT $ 1 00
�W. cCURB'J 'ML
M.L.
TO P.L.
AUTHORIZATION TOTAL FEE G'OA/N. p/y .eEt/ A'/,�s7-
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THE PUBLIC SEWER APPROVALS INSPECTOR'S SIGNATURE DATE
AA
SIGNED THIS._...../.....DAY OF...lX�vl/.._......IA/.-.� NEW HOUSE SEWER
OWNER OR NI BUI1L0 NG OR WORK
NECT ADDITIONALOWNERS AGENT 444...--- ...---
�JJ�F SEPTIC TANK,SEEP.PIT(S)
ADDRESS - ---- ------ AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI. CESSPOOL 0 DRYWELL E] '
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
1 HEREBY CERTIFY THAT 1 AM PROPERLY flEq ISTERED
DISCONNECT PLUG AND
AN
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 DE CRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE SEEP.PIT(S)� CESSPOOLS i
S ` / / - �,I `L ...
OF PERMITTEE._... ..- C. it C+'/✓l
7GA692D 663 -1/53
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ISA8420
CEeDe 8=99 APPLI AT90FO—R PERIVIIC
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL-
DEPARTMENT OF COUNTY ENGINEER
RUD.DING AND SAFETY DWI fIl BUILDING
IORN A. LAIE. COunty Engineer ADDRESS
LAM
.:-
CASSATT D. GRIFFIN, Supt 0f Building LOCALITT\ -�-
NEAREST
FORAPPLICANT TO FILL MN CROSS sS U
AL
DESCRLE IPTION LOT NO. 1 //y) ('jX9 OWNER
BLOCK TRACT _ MAIL
�_Q( ADDRESS
�a NO'OF SLOGS.
SIZEOF LOT' 3 NO'OF SLOT CIT T-1.
`NO
USE OF
BUILDINGS DISTRICT N0. GROUP, MAP - PROCESSED BY
PG
CONTRALTO �
ADDRESS " CONNECTION DATA
CITY EL. STATION DEPTH
MANHOLE'REFERENCE UPPER
REGISTRATION NO. /c_/ e� COUNTY LOWER
NO. DESCRIPTION OF WORK. ' FEE
HOUSE SEWER CONNECTING TO '
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK.SEEPAGE PIT OR Y.. -CURB P.L. M L.
PITS AND/OR DRAINFIELD @ 59.00 M,
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.. CESSPOOL.DRY E LL @ $2.00
RI SE$-0 EROSAL SYSTEM TO @ 81.0 .C'.N0. 35�n LS
Co.Co.'IMP.
CO T ITIONAL BL TRUNK PERMITNO.. 0 RM
W U R g 00
A ER,REPAIR OR ABANDON HOUSE .STATE EN CR�'L/")F}��1T
R OR DISPOSAL SYSTEM @.$I. O PERMIT NO. Wr..L�1 CJ,
INDUSTRIAL '
WASTE APPROVAL
CHARGES
OWNER'S PERMIT E '2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 3 REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT 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 19_. , NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERSAGENT' BUILDING.OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
STATE
AND/OR.DRAINFIELD
I H 'ACKNOWLEDGE THAT I HAVE .READ THIS APPLICATION
AND STATE THAT ABOVE CORRECT AND AGREE TO COMPLY CESSPOOL DRYWELL ❑ I
WITH ALL COUNTYY ORDIORDINANCEE S-AND STATE LAWS REGULATING qLT ER,.REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM NE LEGAL OWNER THE ABOVE
DESCRIBED RESIDE P RTY. SEEPFILL(SEP OCCESSP00❑L3 ❑. -
SIGNATURE
OF PERMITTEE
®r V DATIOROBERT A. WOOD
CN. . M.0. CASH SUPERVISING MECHANICAL ENGINEER
• llt1Co 1 7 1 9 0 Ju"i 3 1 .0 3 .00- ;