HomeMy Public PortalAbout10644 FAIRHALL ST_Sewer__ DEPARrAlENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
DIVISION OF`BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES //
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
I ADDRESS b �O 54 /
FOR APPLICANT TO FILL IN J LOCALITYBUILDING
NEAREST
ADDRESS �� 77 _(J �� CROSSST
LOCALITY Jr—(////y�1 �[�> DISTRICT NO SERIAL NO [PEE�R(MIIT NO
NEAREST A / 9 v C.Tom"// S
CROSS ST
RECEIVED B,YY Ready for Inspection DATEfISSU`ED�
OWNERMAIL
ADDRESS USE ZONE ��O/CCUPANCY BK MAP PG
CITY TEL NO )q �� 911S1tv � / I � / v
CONTRACTOR 0y , CO.
IMP-NO
ADDRESS �s• I _ _ JOB NO !! fes@
CITY /1n� TEL NO 'Q , e P /-yy;? TRUNK PERMIT NO
(� STATE �—
REGISTRATION NO ��� 6 /� �+ ]��=CGUATY ROAD PERMIT NO
LEGAL
DESCRIPTION LOT NO STATE ENCROACHMENT
�j PERMIT NO
BLOCK TRACT ���7 INDUSTRIAL
ASTE APPROVAL
SIZE OF LOT NO OF BLDG$
NOW ON LOT CHARGE$
USE OF ez �/ I NI-1
BUILDINGS �/��� CONNECTION CHARGE FEE
NO DESCRIPTION OF WORK FEE /
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE /
PUBLIC SEWER 0 $ 350 RECEIPT NO I ,DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLD6 OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING NO I `
SEWER OR DISPOSAL SYSTEM 1 00 C DATE BY
DISCONNECT AND ABANDON SEWER
AHD/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 200 STATION DEPTH G /
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 I / VV MANHOLE REFERENCE
Y 1/ Z,� UPPER LOWER
TYPE OF CONNECTION L� LENGTH FROM /
I Y'� CURB- P L M L TO P L S
OWNERS PERMIT $ 1 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 S G G I 2 S3
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT _ _ _ BUILDING OR WORK
ADDRESS _ _ SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL Ej 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 IAM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY BACKFI LL SEPTIC TANKS E]
SIGNATURE SEEP PIT(S)[] CESSPOOLS
OF PERMITTEE
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