HomeMy Public PortalAbout10650 FAIRHALL ST_Sewer__ S
EDEPAWrAMNT OF COUNTY ENGINEER SEVER—SEWAGE DISPOSAL 7
' DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION 1
COUNTY OF LOS ANGELES I
WILLIAM J. FOX, COUNTY ENGINEER J BUILDING
ADDRESS d C�..1✓ d
FOR APPLICANT TO FILL IN LOCALITY
BUILDING �v� C��+�I NEAREST
ADDRESS �� (/(� � CROSS ST
LOCALITY �,'7' u_� DISTRICT NO SERIAL NO PERMIT NO
NEAREST bC.,�'"'4d l
S— A / SSC /o S
CROSS ST �
IT
OWNER
tea, RECEIVED BY Ready for Inspection DATE ISSUED
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TEL NO � eCC
CONTRACTOR l �►d� ���6 Qt�il��X31 �",A,�' 'I �C0111-IMP-NO 74
ADDRESS / JOB NO S
CITY - TEL NO STATE��y TRUNK PERMIT NO
REGISTRATION NO
�� T P�COUNwTY 1
ROAD PERMIT NO
LEGAL p
DESCRIPTION LOT NO STATE ENCROACHMENT
PERMIT NO
BLOCK TRACT / 9 ) INDUSTRIAL
NO OF BLDGS WASTE APPROVAL
SIZE OF LOT NOW ON LOT CHARGES
USOF
BUELDINGS CONNECTION CHARGE FEE
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
REIMBURSEMENT FEE
PUBLIC SEWER @ $ 3 50 U RECEIPT NO I DATE yes I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR t EXCEPTION RECORDED
WORK TO HOUSE SEWER 1 00
ALTERR OR REPAIR EXISTING NO h 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/OR DRAINFIELD 200 STATION O DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200
iC 57 ANHREFERENCE
_UPOLE LE 1-OLifbR
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ 1 00 �Y.� CURB (P-/ ML TO P L
AUTHORIZATION TOTAL FEE 4-� 'r-p
1 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
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT _ _ _ _ _ BUILDING OR WORK
ADDRESS _ _ _ SEPTIC TANK SEEP PIT(S)
I AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL[] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE'
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS1 ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS j SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM 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 I BACKFILL SEPTIC TANKS El
SIGNATURE S. �d� SEEP PIT(S)� CESSPOOLS
OF PERMITTEE _�tA-�''Y-� � (aA
76A642D 663 1/53 �4bi � �' �. T �(/ lam,