HomeMy Public PortalAbout9167 FORTSON DR_Sewer__ 5&E66312.54 A• • LICATIOW FA • Z0 •,�Y ■ � 1
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE ®!SPOSAL
Department of County Engineer
County of Los Angeles BUILDI
WM. J. FOX, COUNTY ENGINEER AD RE
CASSATT D: GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST:
LEGAL
DESCRIPTION LOT NO. OH,
BLOCK TRACT /jJ,• y -MAID '
ADDRES
NO. OF BLDGS.
SIZE OF LOT. NOW ON LOT T TEL. NO.
USE OF y
BUILDINGS �(�j11 DISTRICT O. IGROUP MAP
CONTRACTOR ' BK PG
ADDREss, jj g CONNECTION DATA
CIT f TEL �s STATION `�4—/7, DEPTH
/� STATE � i- 1 MA REFERENCE
REGISTRATION'NO./J} 1 �? �( ❑ COUNTY jF/4,S � UPPER
Jc
[y _7 (�' TYPE OF CONNEC LENGTH FROM
NO. DESCRIPTION OF WORK FEE Y. CURB P.L. M L.TO P. L. t7
HOUSE SEWER CONNECTING TO
PUBLIC•SEWER t@ $ 3 50
HOUSE SEWER CONNECTING TO -
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT
WORK TO HOUSE SEWER 1.00 /��/
CONNECT ADDITIONAL BLDG. OR CO. IMP. N0. JOB. NO.
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT N0. 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
CONNECTION CHARGE FEE
•OWNER'S PERMIT g OO
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
HAVE 7RACTORTT05 CONNECTDATE OTHEAABOVECTED WDESCRIITH H D EXES NINGHERIA DW ELLIMED ONG APPROVALSDATE -INSPECTOR'S SIGNATURE
TO THE PUBLIC S W R, ��'
- �0 1,,�j HOUSE SEWER
SIGNED THIS DAY OF 7-2.1SA.
OWNER OR • Ja-� CONNECT ADDITIONAL
OWNERS E BUILDING OR WORK
SEPTIC TANK,-SEEP, PIT(S)
ADDRE AND/OR DRAINFIELD
1 HEREBY ACK OWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL[IDRYWELL[:1
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
IHEREBY 'CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE-SEWER
CALIFORNIA OR THAT J AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PERTY BACKFILL SEPTIC TANKS❑ F2-1,-'-I-
ASEEP. PIT(S) ❑ CESSPOOLS /_" 4�.CS�J�f••
SIGNATURE
OF PERMITTE /
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
(Co 5 8 9 4 Jul-2 2 4 45 C ;
,BY BY -
DEPUTY DEPUTY
By
By
-AD DEPUTY DEPUTY