HomeMy Public PortalAbout10659 FAIRHALL ST_Sewer__ DEPAU.rMENT OF COUNTY ENGINEER, SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESSy -
FOR APPLICANT TO FILL IN LOCALITY
BUILDING ADDRESS �� J NEAREST <U /ln, �-
CROSS ST `r 1��,� V
LOCALITY n DISTRICT NO SERIAL NO PERMIT NO
NEAREST \` "� A
CROSS ST c�
�/fJ�� ,/RECEEIIVEED,�jB�Y` Ready for Inspection DATE ISSUED
OWNER € U`J1/ 61k- '�` �� ( `
MAIL
ADDRESS �'" I USE ZONE OCCUPANCY MAP
BK PG
CITY0 TEL NO�r � ,e 4 _ '
CONTRACTOR /
ADDRESS
JOB NO 5 5-
CITY TEL NO rya, �I �p2,-?j?" TRUNK PERMIT NOTATE '
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REGISTRATION NO ��� �J `. ��COUN-TY-
ROAD PERMIT NO
LEGAL
DESCRIPTION LOT NO STATE ENCROACHMENT
PERMIT NO
BLOCK TRACT / �/ 79 INDUSTRIAL
NO OF SLOGS WASTE APPROVAL
SIZE OF LOT --�7 NOW ON LOT CHARGES
USE
BUILDINGS
� `� CONNECTION CHARGE FEE /
J��I
NO DESCRIPTION OF WORK FEgP' REIMBURSEMENT FEE /
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q $ 350 RECEIPT NO I DATE I BY
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLD6 OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1 00 i
ALTER OR REPAIR EXISTING NO
SEWER OR DISPOSAL SYSTEM 1 00 BY
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR _
PITS AND/OR DRAINFIELD 2 00 /
CESSPOOL—DRYWELL STATION 3-f L�� DEPTH
SPECIAL CONDITIONS ONLY 200 M NHOLE REFERENCE
UPPER LYItVAEA
TYPE OF CONNECTION LENGTH FROM i
OWNERS PERMIT $ I 00 CURB- P L 4 M L TO PL 5
AUTHORIZATION TOTAL FEE 1 ,il*T
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
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS _ - - - -- PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI.j' 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 THATRE AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA ORTHAT I AM THE LEGAL OWN-j ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS
SIGNATURE � � �°� �� E SEEP PIT(S)� CESSPOOLS
OF PERMITTEE I �"'�'�/ c
e
76A642D 663 1/53 %/ e/a�1����' i,