HomeMy Public PortalAbout5038 DOREEN AVE_Sewer__ DEPARTDfFNT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER ,I BUILDING
ADDRESS _5o3S dsJ c�T-PPYI
FOR APPLICANT TO FILL IN LOCALITY C ,
BUILDING C NEAREST
ADDRESS 5Q 3 �.7/��h CROSS ST. A V e
LOCALITY7__ � / DISTRICT NO. SERIAL NO. IRS(!)
1NO. C
NEAREST A t -` �lO { _
CROSSST. .
y• L RECEIVED BY Raetly for Ineoectian DATE ISSU EO
OWNER ✓Ol/G �..�l.f�l'�/I�1./ ��eC.��C� � 1.Z- '��s `�
MAIL c USE ZONE OCCUPANCY MAP
AD DRES�S�.SQ 1,%=2 /!J r[� /7/ p BK PGG
CITY /C/J9IJ/P ClT4 TEL.NO. /' IY-I V
� ' 1.-.:— A
CONTRACTOR���nr�n/j! IK?Al71 C o , CO.IMP.NO. - `2
ADDRESS 7�9� T
/7X ..217 JOB.N0. ^�
TEL.NO. / �.3/�/ TRUNK PERMIT NO.
REGISTRATION NO. 'C? COUNTYJ�
ROAD PERMIT NO.
LEGAL Q STATE ENCROACHMENT -------1511
DESCRIPTION LOT NO. / PERMIT NO.
BLOCK TRACT �� INDUSTRIAL
WASTE APPROVAL _
SIZE OF LOTN0.OF SLOGS. CHARGES /
/oaX2Oo NOW ON LOT L
USE OF ^� /BUILDINGS CONNECTI HARGE FEE
/EYP I/ �/'I/b /?'�l�
NO. DESCRIPTION OF WORK FEE REIMBURSEMENTF
HOUSE SEWER CONNECTING TO
PUBLICSEWER 01 3.50 RECEIPT NO. DATE IBY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECOtDGk
WORK TO HOUSE SEWER 1.00 NO
ALTER OR REPAIR EXISTING DATE
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
ANO/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR )
PITS AND/OR GRAINFIELD 2.00 STATION 160 .R-`F; DEPTH �p
CESSPOOL—DRYWELL
SPECI AL CO N DITIONS ONLY 2.00 I MANHOLE REFERENCE
UPPGR OWER
TYPE OF CONNECTION LENGTH FROM /
OWNERS PERMIT $ 1 00 V%- M.L.TO P.L.
AUTHORIZATION I TOTAL FEE /-. o
CONTRACTORHAVE
TDO ATE CONNECT THECONTRACTS
ABOVE DESCRIBEDWITH THE 1 EXISTING ED APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS.._- ._DAY OF._Z�'—__._19 NEW HOUSE SEWER
OWNER OR �,e.41�f.� 1 � CONNECT ADDITIONAL
OWNERS AGENT.:_..�.._G._..... _ BUILDING OR WORK
.r_ _.._____..__.._._.._.._.._.._..._
O Q/,�� SEPTIC TANK,SEEP.PIT(S)
ADDRESS..._..... _......_�4�.... - - �....__.._.......... AND/OR DflAINF1ELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI• CESSPOOL[] DRYWELL I]
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
Eft OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS in
SIGNATURE -' SEEP.PIT(S)Q CESSPOOLS /✓A!/.f.„ ,�.� �L'Pl�
OFPERMITTEOa.GIA_
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