HomeMy Public PortalAbout5021 DOREEN AVE_Sewer__ DEPAICTGTENT OF COUNTYFSTcnvEETt I
SEWER—SEWAGE DISPOSALE� V3SION OF BUILDING AND SAFETY ` PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER II AIILDINGyS-OZ/
ADDRESS
FQR AgWCTFILL IN LOCALITYBUILDING lO �/ u.. CAos55T.ADDRESS JLOCALITYDISTRLCT N0. SERIAL N0. .PERMIT N0.
NEAREST A CROSS ST. RECEIVED B :Ready lar Inspection DATE ISSUED6
OWNER ,r ��
MAIL /l USE ZOIo, OCCUPANCY MAP
ADDRESS J � 17-11
}y-� / -. �+ /BK PG
CITY �/f TELAO./D .Pd 2,. 1 / / —` /��J LQ 39
CONTRACTOR
ADDRESS C SU SCI/(/L L-.!U JOB NO.
CITY .��� �8 �.�f EL.NO. ' ���jy�A1• TRUNK PERMIT NO.
REGISTRATIONNO. / f 9 $CO1171TTY ROAD PERMIT NO.LEGAL * TATE
DESCRIPTION LOT.NO. ZO ' 7,,4 ge Sco' P ERMIT NOROACHMENT '
BLOCK TRACT Z/ 2 9� r-p TSS INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT N0.WOOF N BLLODTGS. / CHAR S
O A NO
USE OF
BUILDINGS I'4!?dcs�S CONNECTION CHARGE)IkE
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER 0 $ 3.50 RECEIPT NO. DATE BY
HOUSE SEWER CONNECTING TO
PR IVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION ECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIREXISTING NO. I DAT IBY
SEWER OR DISPO S AL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
ANO/OR DISPOSAL-SYSTE M 1.00 CONNECTION DATA
SEPTICTANK, RAI NFIEPIT OR / i�. O
PITS AND/OR GRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL p ,
SPECIAL CONDITIONS ONLY 2.000 /�1 MAN�IOLEx@EFERENCEAnI .L�
O �,J (UPPERR� COWER`
TYPECTION LENGTH FROM
OF �j t+
OWNERS PERMIT $ I TCDD - 71C"UR4f{7 M.L.TO P.I. _
AUTHORIZATION TOTAL FEES
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
.. _ HAVE
TO CONNECT THE ABOVA DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO T/yy/E��{PUBLIC SEWER
SIGNED THIS....d.IL__:_:.DAY OF...... .. ._L.:L__-..:..19.. NEW HOUSE SEW ER
OWNER OR CONNECT ADDITIONAL
V
OWNERS AGENT.... . . .. BUILDING OR WORK
SEPTIC TANK.SEEP.PITS)
ADDRESSz�.LL------- .. __.._..... ......_........-._.........-_. AND/OR GRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL[:] DRYWELL
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 ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE ABOVFy� CI{�§EDJIESIDE XI OPERTY BACKFILL SEPTIC TANKS E
�/ LV'y [G`/i'7/i �-o SEEP.PIT(S)0 CESSPOOLS -%
SIGNATURE I' //I-
OF PERMITTEE..... . _ �Y-... N�J� r/1�- -----
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