HomeMy Public PortalAbout4814 FIESTA AVE_Sewer__ 1166
&a 78AAPPLICATION FOR PERMIT 1
7:A� DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL.
Department of County Engmeer
` County of Los Angeles BUILDING
WM J FOX COUNTY ENGINEER ADDRESS
CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN "O'S ST
DESCRIPTION LOT NO OWNER
BLOCK TRACT M� 9�
ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT / CITY TEL NO
USE OF �n /'
BUILDING IA)�4 DISTRICT NO GROUP MAP
BK PG
CONTRACTOR I/� "�"�� 45, 1 _r I 2— 9�
ADDRESS f �� vI CONNECTION DATA
CITY S TEL NO �, , STATION P ILys S, DEPTH
�Y7 R S ❑ STATE MANHOLE REFERENCE ---/!!!! 7 �5
REGISTRATION NO /�.,v ❑ COUNTY ONER�
DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TOTYPE ECTI LENGTH FRO d
PUBLIC SEWER Q $ 3 50 Q �� CURB M L TO P L `
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
— ORK TO HOUSE SEWER 1 00 CO IMP
ADDITIONAL BLDG OR _ , L / 6 P C NO
1VMP NO 'T JOB NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
/0 A-)
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 1100 INDUSTRIAL
CESSPOOL DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
OWNER'S PERMITs 1 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE v REIMBURSEMENT FEE
TRACTORHAVE TTOS CONNECT THEDATE AABOVE DESCRIBED EXISTINGCTED WITH THE HEREIN AMED DWELL G APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
q
SIGNED THIS �R\ABYNEW HOUSE SEWER
, OF\ J 19_
OWNER OR �, 1 , \C CONNECT ADDITIONAL
OWNERS AG EI JJ ��`\\\ BUILDING OR WORK
� SEPTIC TANK SEEP PIT(S)
ADDRESS Z AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATIONCESSPOOL❑ DRYKELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEVER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
IICHEREBY CERTIFY THAT 1 AM ��DgRRpDPERLY REGISTERED AND/OR
LENSED AS REQUIRED BY LOSA'NGELES COUNT AND STATE OF DISCONNECT PLUG AND
CALIFORNIA TH R I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWEP OR
_
DESCRIBED S DEN IAL PROPE)TYBACKFILL SEPTIC TANKS❑ Q _
SEEP PIT(S)-[] CESSPOOLS
SIGNATUR
OF PERMI E
WILLIAM J FOX LINTY ENGINEER ALWATION R A WOOD CHIEF PLBG INSPECTOR
17 , 11 J Iii
v )/