HomeMy Public PortalAbout10610 FAIRHALL ST_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER - SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY .I PERMIT APPLICATION- -
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING /Z
ADDRESS OZ (
�j LOCALITY
FOj ABUILDINGPPLICANT TO FILL I I
NEAREST
ADDRESS ( �fp d C� c ` ' ' CROSS ST. I
LOCALITY DISTRICT NO. ~A SERIAL NO. PERMIT NO. c
NEAREST � �� �L 9 �� J
CROSS ST.
RECEIVED BY Ready for Inspection -DATE ISSUED .
° OWNER
44
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ADDRESS flr .�� z ! JOB NO.
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CITY / /TEL.NO. / ����X( TRUNK PERMIT NO.
LEGAL
RSTATE
EGISTRATION NO. r/2 L /�� ` _ �jH COUNTYI
ROAD PERMIT N0.
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DESCRIPTION LOT NO. / ' STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT / INDUSTRIAL
WASTE APPROVAL \�
SIZE OF LOT NO.OF BLOCS.
NOW ON LOT CHARGES
USE OF �-f�,/�
BUILDINGS �..1/�- p� l/7 � 4, CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEy,- REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC_SEWER @-S 3.50 v v, RECEIPT N0. kZATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Izo0
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER ' 1.00 1
ALTER OR REPAIR EXISTING -NO- Imo- DATE BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE-PIT ! /
PITS AND/OR DRAINFIELD 2.00 i !'4-f�� DEPTH
CESSPOOL—DRYWELL STATION �, Q -
SPECIAL CONDITIONS ONLY 2.00 / / c MA_NHOLE REFERENCE
!c1 Gar G �-f UPPER tQ1KER
TYPE OF CONNECTj10N N _,LENGTH FROM
OWNERS PERMIT $ 1 00 q J
.Y euRt3 P.L. M.L.TO P.L. .0
AUTHORIZATION I TOTAL FEE O Fl
1 HAVE THIS DATE CONTRACTED WITH.THE HEREIN NAMED;
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINGf
DWELLING TO THE PUBLIC SEWER' APPROVALS INSPECTOR'S SIGNATURE DATE
SIGNED THIS-------------------DAY OF--------------------------------- ---19......- NEW HOUSE SEWER 5'�
OWNER OR .) CONNECT ADDITIONAL
OWNERS AGENT-------------------------------------------------------------- BUILDING OR WORK
,
ADDRESS - - --- SEPTIC TANKSEEP.PIT(S)
--•------•------------------•---........................, AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI CESSPOOL E-] DRYWELL D
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE),
TO COM17PLY WITH ALL COUNTY ORDINANCES AND STATE LAWS') ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTYjDISCONNECT PLUG ANDI ABANDON HOUSE S EWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. I BACKFILL SEPTIC TANKS
SIGNATURE - I�r 1 SEEP.PIT(S)[:] CESSPOOLS E
OF PERM ITTEE--_-L?------1_�-:. D-er� ......
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