HomeMy Public PortalAbout9161 FORTSON DR_Sewer__ 76A6420 A P P L I C A ■ I O W• FOR PERMIT
Y 6&E-663 12-54
DMSION OF BUILDING AND SAFETY SEWER—SEWAGE O I S POSH L
Department of County Engineer
County of Los Angeles BUILDING
ADD
SG /
WM. J. FOX, COUNTY ENGINEER
CASSATT D. GRIFFIN. Sup•T OF BUILDING LOCALITY �"{�jfl.•�" f
FOR APPLICANT TO FILL IN • NEAREST
CROSS ST.- �.,I3✓�-
LEGAL `f
DESCRIPTION LOT N0. 3 5-4 OWNE
o�
BLOCK TRACT l MAIL A.I/
ADDRESS
NO. OF BLDGS. �•
SIZE OF LOT NOW ON LOT CITY ,,,s�,.,. i TEL. NO. -
USE OF "
BUILDINGS i.- -'t DISTRICT N . G OUP MAP
_ I I BK PG
CONTRACTOR /4�2I0ADDRESS
CONNECTION CONNECTION DATA
c ..cam
Cl/ TEL.6 t STATION � - DEPTH
❑ STATE MANHOLE REFERENCE
REGISTRATION NO. ❑ COUNTY ./ ) r ` - UPPER Lq)YER
TYPE OF CONNECTION LENGTH FROM �ba
NO. I DESCRIPTION OF WORK FEE -Y-1- OURAzt P.L. M.L.TO P.L. '
HOUSE SEWER CONNECTING T0,
PUBLIC SEWER Q S 3.50 yL(f
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00 -,�
CONNECT ADDITIONAL BLDG. OR CO. IMP. N0. , ;fir�� JOB. NO.
_ WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING
_ SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL - WASTE APPROVAL
SPECIAL CONDITIONS,ONLY 2.00 CHARGES
PERMIT CONNECTION CHARGE FEE
OWNER'S t O0-,
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
TRACTORHAVE T TO CONNECT THEHIS DATE AABOVCTED WIE DESCRH EDHEREIEXISNINGA NAMED DWELLING _APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC W R
SIGNED THIS DAY OF 17- NEW NEW HOUSE SEWER 7
- 1,46
OWNER OR CONNECT ADDITIONAL �� �/G%'
OWNERS GEN • BUILDING OR WORK
ADDP. 2 SEPTIC TANK,SEEP, PIT(S) ,
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 THE LEGAL OWNER OF T E ABOVE
DESCRIBED RESIDEN OPERTY. BACKFILL SEPTIC TANKS❑ rl_ /[�(1,UIi
SEEP. PIT(S) ❑ CESSPOOLSOld-if
SIGNATURE -
OF PERMITT - -
WILLIAM J. OX, OUNTY ENGINEER VALIDATION
'
BY .._,tC0 66Y0 5 P�'r`, JUL�� 4 4 ,5 Q rn
DEPUTY DEPUTY
BY BY /"-A
DEPUTY
_
® ' DEPUTY /l� '1 .c�y— -�/ .°`-y: t' p% DEPUTY
o
CE80810-63
76A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING61 _d�TSoN L)JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Supt of Building 72� G 1ei
LOCALITY
NEAREST It �� d Al �.• x
FOR APPLICANT TO FILL IN Ross ST v
DESCRIPTION LOT NO 3 OWNER
BLOCK TRACT -r J / MAIL ADDRESS q/ -_DJ OAl
NO.
SIZE OF LOT SJR /1 y/-=2Q NOW OONB LOTS CITY L. NO. (I
USE OF t
BUILDINGS P C DISTRICT NO GROUP MAP P-R ED
BY
BK PG
CONTRACTOR `
ADDRESS ,,',�v lJ 444 CCfNiFECTIO ATA
CITY TEL NO STATION )r DEPTH
❑ STATE MANHOLE REFERENCE � � /�J UPPER
REGISTRATION NO ❑ COUNTY �•!/R/i" ' :S:G1EiS,A'
NO.•, DESCRIPTION OF WORK FEE TYPE F NNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y C RB P L M L TO P L. d
PUBLIC SEWER @ S5 00 1 /0 y
SEPTIC TANK,SEEPAGE PIT OR ��/ , C.NO. O
PITS AND�OR DRAINFIELD @ SIO 00 CO IMP. NO. JOB NO. V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. 9=I''RIVATE DISPOSAL SYSTEM @ S3 00 0
CONNECT ADDITIONAL BLDG OR �h AFFIDAVIT I WAIVER I EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ 5300 V
OVERFLOW SEEPAGE PIT,DRAINFIELD {JJ
EXTN,C ESSPOOL,DRYWELL.MANHOLE @ SS 00
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM @ 53 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ z 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF _19—
OWNER
9_OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL 1 ��'•� L_ +'"���� ,� �� /��
ADDRESS
BUILDING OR WORK /p1
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY.. ABANDON HOUSE SEWER
SIGNATURE / / BACKFILL'SEPTIC TANKS ❑
OF PERMITTEE `L SEEP,PIT(S) ❑ CESSPOOLS ❑
ALIDATIOi(`J / ROBERT WOOD
CASH
CK. M.O,
l� SUPERVISING MECHANICAL ENGINEER
Lt ye 9;6;0 8 JUN 3 1 0 D 5.0 0- v