HomeMy Public PortalAbout10638 & 10636 FAIRHALL ST_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER--SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING pp��
I ADDRESS /L'
FOR APPLICANT TO FILL INA LOCALITY ��,�
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ADDRESS !� EA „ CROSS ST
LOCALITY DISTRICT NO SERIAL NO PERMIT NO C
NEAREST I 1 A
CROSS ST
��,,��OJ //ff RECEIVED BY Ready for Inspection DATE/ISSUED
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CONTRACTORftp 141-0A?"114 tPy C074-MP,--NOyj !I JCI'
ADDRESS � / L��� y r I' JOB NO
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CITY Cq TEL NO Ae ,® I � � TRUNK PERMIT NO
REGISTRATION NO /_P °D m t1A H_STA E'
ROAD PERMIT NO
LEGAL /� STATE ENCROACHMENT ~+e
DESCRIPTION LOT NO `\
PERMIT NO
A
BLOCK TRACT INDUSTRIAL A
_ WASTE APPROVAL �
SIZE OF LOT NO OF BLDGS
NOW ON LOT CHARGES _
USE OF
BUILDINGS � CONNECTION CHARGE FEE
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER @ j 350 q F! RECEIPT NO I DATE1� I BY
v HOUSE SEWER CONNECTING TO — I
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING NO 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/ORDRAINFIELD 200 STATION /+ DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 (br �L,P7 g ! MANHOLE REFERENCE
/ UPPER LOWL-B
TYPE OF CONNECTION'—, LENGTH FROM /
OWNERS PERMIT $ 1 00 "Y— CURB r, P L J ML TO P L
AUTHORIZATION I TOTAL FEE fj 1
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
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 S G m2—,7;z
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT _ _ _ _ _ _ _ BUILDING OR WORK
I SEPTIC TANK SEEP PIT(S)
ADDRESS _ _ _ _ _ - - AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI CESSPOOL 0 DRYWELL
CA
TIONAND STATE THAT THE ABOVE IS CORRECT AND AGREE'
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS I ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY,,
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-` DISCONNECT PLUG AND
ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY BACKFI LL SEPTIC TANKS C]
1 SEEP PIT(S)� CESSPOOLS
SIGNATURE � / A
OF PERMITTEES 1 _� •
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