HomeMy Public PortalAbout5010 DOREEN AVE_Sewer__ T ` DEPARTAIFy-T OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL '9
DIVISION O BUII:DING AND SAFETY PERMIT APPLICATION 8
COUNTY OF LOS ANGELES
j WILLIAM J. FCX, COUNTY ENGINEER I ADD EISS n
LOCALITY
FOR APPLICANT TO�rFILL1�I�SN
[MAIL
ILDING �� I(�", ��I!\ G�I• CROSS ST. ✓
ADDRESS 1
CALITY jj'� L�;. DISTRICT NO. SERIAL NO. PERMIT NO.
� � �AREST L/ 1 je Jl / ,( � A \ ,� A /Z ' � / SS�S
OSSST. {4 /V �°'/ 1///1,y! ,I1 � //� RE/CIEIVEaO.BY, RenOy for InaOentlon /DATEISSUEDWNER �� ! /f 14" �y7'Ii� V / l/1.,,VY ,17 /j
ADDRESS �..({/f USE ZONE OCCUPANCY - 'MAP
BK' PG
CITY ., TE100(y. J
CONTRACTOR �.2f"L!� (-, 3 t.
CO.IMP.N0.
ADDRESS
108 N0.
CITY TEL-N0. ,7'Ql�jrTRUNK PERMIT N0. n
REGISTRATION NO.(ro—�-/� �'�'G [] CSOUNTY
ROAD PERMIT NO.LEGAL
DESCRIPTION LOT NO. �� -S'Oc:f'N ' Z STATE ENCROACHMENT
L PERMIT NO.
BLOCK TR�ACCT •� / � WASTE APPROVAL
512E OF LOT'4 r jY `�J INO.BF NOW ON LOTS / CHARGES
USOF
BUEDINGS / �'l�C/,L/�,�� CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER ® $ 3.50 RECEIPT NO. DATE IBY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE S EWE R 1.00
ALTER OR REPAIR EXISTING NO. I DATE IBY
SEWER 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 /� ���� � DEPTH (-I'
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 3 `./, 2 / NUPPER'REFERENCE AJW LOWER
TYPE OF CONNECTION LENGTH FROM%% 4� C
OWNERS PERMIT $ 1 00 Y-lam CURB •P-.Ln M.L.TO P.L. V 7J�
AUTHORIZATION TOTAL FEE T
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE/PUBLIC SEWER
SIGNED THIS--------.._-_-_.DAY Of... ------------- 19_. NEW HOUSE SEWER
OWNER OR �A1y CONNECT ADDITIONAL
OWNERS A T--.. .. _-.. .. n ..---..-^-----`......._ BUILDING OR WORK
ADDRESS...--. �._C .... "�' SEPTIC TANK.SEEP.PITS)
---"---- `--------'-------_ AND/OR TANK.SEEP.
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI CESSPOOL D 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 _
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG
AND/OR AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSESAND
AND STATE OF CALIFORNIA OR THAT I AM TXE LEGAL OWN-
ER OF THE ABOVE ESCRIBED R IDENTIAI/PH PERT BACKFILL SEPTIC TANKS Ej
SIGNATURE �• / SEEP.PIT(S)Q CESSPOOLS
OFPERMITTEE . .- - --Si._...-- - --- -------------- -------- ...... --
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