HomeMy Public PortalAbout10643 FAIRHALL ST_Sewer__ DEPARrMMNT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 9
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION 1
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN /J / / /// LOCALITY `
BUILDING j_ // NEAREST I
ADDRESS J L�j Q��C/��Jf NEAR ST
LOCALITY � R DISTRICT NO SERIAL NO PERMIT NO
NEAREST
CROSS ST
Xy�, RECEIVED B�YR� Ready for Inspection DATEISSUED
OWNER /?~ y�Ga/ 5Z
MAIL
ADDRESS / � jo/ / �J/L 'USE ZONE OCCUPANCYBK
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CITY TEL NO
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CONTRACTOR
ADDRESS
JOB NO D ��
CITY ��,r �j-Z+i TEL NO 1 G 1 TRUNK PERMIT NO
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REGISTRATION NO / qG e?a (r_P�p=COUNTY
ROAD PERMIT NO \
LEGAL P'
DESCRIPTION LOT NO STATE ENCROACHMENT \
Q PERMIT NO A
BLOCK TRACT / / / 9 INDUSTRIAL \ /
NO OF BLDG3 WASTE APPROVAL
SIZE OF LOT NOW ON LOT CHARGEES /
USE OF �
BUILDINGS � A CONNECTION CHARGE FEE
o
NO DESCRIPTION OF WORK FEE/ �\
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER 0 $ 350 in RECEIPT NO I DATE \ I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OREXCEPTION RECORDED
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING N0,1 I DATEI 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 /'1-76- D DEPTH 6
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 M NUHOLE PPER REFERENCE LbWBR
_yl_TYPE OFCCtOBNBNECTIONP L 4-- LENGT
TOHP L FROM t
OWNERS PERMIT ; I 00
AUTHORIZATION TOTAL FEE
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 $OhydG "0?07 63
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 E] 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 I AM PROPERLY REGISTER..
R DISCONNECT PLUG AND
AND/OLICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS Ej
SIGNATURE -7D moi/ �If SEEP PIT(S)E] CESSPOOLS E]
OF PERMITTEE t47 `' _ �' ?�`
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