HomeMy Public PortalAbout10619 FAIRHALL ST_Sewer__ DEPAIVfMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION _
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING /
ADDRESS /d(p�
FOR APPLICANT TO �F,I.L`L IN� B��q y/C LOCALITY
BUILDING / D G 17 CGi�/LrTiC.�i�fiT G� CROSS ST. � �/s
NEAREST 7tt
ADDRESS
-LOCALITY / DISTRICT NO. SERIAL NO. - PERMIT NO.
NEAREST A ��5��` .'I.�S
CROSS ST.
RECEIVED
�B'Y` Ready for Inspection DATE ISSUED
OWNERMAIL
ADDRESS;e;?-), �4� USE ZONE OCCUPANCY MAP
�y, BK PG
CITY TEL.NO. �� ��
CONTRACTOR/App / p�, /fe . S � � C04-•tMP=ND. �� V 1����VVV� C,
ADDRESS/- any 7
X06 NO. fo S
CITYP 1�r� TEL.NO. ®P � TRUNK PERMIT NO.
'REGISTRATION NO. ',K7-H-Ca),NTY, z
ROAD PERMIT N0.
LEGAL
DESCRIPTION LOT N0. � AA��m•eC STATE ENCROACHMENT
PERMIT N0.
BLOCK TRACT elINDUSTRIAL \ �
WASTE APPROVAL
SIZE OF LOT NO.8F BL
-NOW ON LOT
CHARGES 1
USE OF / f ly0 /
BUILDINGS �f� s�ga��K,d�, CONNECTION CHARGE FEE `
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLICSEWER @ $ 3.50 )
HOUSE SEWER CONNECTING TO RECEIPT N0. I DATE BY
I
PRIVATE DISPOSAL SYSTEM 1.00 1>
CONNECT ADDITIONAL BLDG.OR EXCEPTION-RECORDED
WORK TO HOUSE SEWER -1.00
ALTER OR REPAIR EXISTING NO• I DATE I BY
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 DRAINFIELD 2.00 STATION QTC '' p DEPTH CO
CESSPOOL-DRYW ELL ,/
SPECIAL CONDITIONS ONLY 2.00 / , / MANHHOLLEERREFERENCE W r/ LOWER
T PE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ 1 00 -Y= CURB- P.L. L/ M.L.TO P.L. 'L �
AUTHORIZATION I TOTAL FEE IT DI
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED f
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THE PUBLIC SEWER , APPROVALS INSPECTOR'S SIGNATURE DATE
SIGNED THIS....................DAY OF.......................................19_._..., NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
--------••-----...----
OWNERS AGENT---------------------------------------_-.---------.-_- - BUILDING OR WORK
ADDRESS------------------------------------------------------ SEPTIC TANK,SEEP.PIT(S)
_.._... - =------........ AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL[] 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 IAM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND
DISCONNECT ABANDON HOPLUG PLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE �/ �? SEEP.PIT(S)� CESSPOOLS
OF PERM ITTEE_V..'_.!�.e �'-�! "' :c � G`-�
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