HomeMy Public PortalAbout9173 FORTSON DR_Sewer__ '
:6 8 E•663 12.54 APPLICATION , FO.R PERMIT
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL.
Deportment of County Engineer
County of LOS Angeles BUILDING -
WM.J. FOX, COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN. SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS ST. :_ 47
LEGAL
DESCRIPTION LOT NO. OWNER/j i •
BLOCK TRACT MAIL Wj
ADDRE
NO. OF BLDGS.
SIZE OF LOT NOW ON L T CITY TEL.
USE DI v
BUILDINGS DISTRICT N I GRUP BK MAPAP
PG
CONTRACTOR
c77
.wk
RESS' CONNECTION DATA
T STATION a �(A / , DEPTH J
_ STATE MANHOLE REFERENC ✓i` ���� LOWER
REGISTRATION N0. � � � % � Gf ❑ COUNTY UPPER ` '
IK�—J TYPE OF CONNECT! LENGTH FROM
No. DESCRIPTION OF WORK FEE Y. CURB P.L. M.L.TO P.L.
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $ 3.50
HOUSE SEWER CONNECTING TO 4-11
.PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO. IMP. NO. JOB. N0.
_ 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
_
ITS AND/OR DRAINFIELD 2.00 INDUSTRIAL.
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 C GES
CONNECTION CHARGE F
OWNER'S PERMIT g 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
TRACTORHAVE TTO CONNECTHIS DATE ONTRTHEA ABOVE DESCRIBED EXCTED WITH THE ISTINGA DWELLIED ONG APPROVALS DATE' INSPECTOR'S SIGNATURE
TO THE PUBLIC SE ER it
SIGNED THIS DAX OF NEW HOUSE SEWER .{� Ir I '
) -� 19 54" B i/G�'186
OWNER OR / CONNECT ADDITIONAL
OWNERS Ar r.
- BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDR 1 f ;Z3db�4C4AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL[IDRYWELL❑
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 1 AM THE LEGAL OWNER OF TH ABOVE
DESCRIBED RESIDENTIA}, l� ERTY. BACKFILL SEPTIC TANKS❑ L/
CESSPOOLS LIIC � ;pJ 20pQ _/SEEP. PIT(S) ❑
SIGNATURE
OF PERMIT �
WILLIAM J. FO , COUNTY ENGINEER VALIDATION
7 4 9 ^v SEP ? 4 4.50 In
BY BY
y DEPUTY DEPUTY
BY BY /
0 DEPUTY DEPUTY