HomeMy Public PortalAbout10619 FREER ST_Sewer__ 6 Q E•663 12.54
DMSION OF BUILDETY BUILDING AND SAFSEWER—S EWA D/
APPLICAT10K.. 17011 PERMIT
S OSA L,
Deportment of County Engineer
County of Los Angeles BUILDING
WM.J. FOX. COUNTY ENGINEER ADDRESS fes'
CASSATT D. GRIFFIN;SUPT OF BUILDING LOCALITY V/
FOR APPLICANT TO FILL IN NEAREST „� �} L, ,� ✓ ,�
OSS ST.
LEGAL
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—DESCRIPTION LOT NO. OWNER �//�� ///"J
BLOCK TRACT '11c;2f�
ADDRESS 11,10!�RESS cal
SIZE OF LOT �K../^ ® N WOONBLOTS. CITY
/ � �d �� TEL. N0.��
USE OF
BUILDINGS �6s//��
ga1 DISTRICT NO. GROUPI MAP
,- BK PG
CONTRACTOR zt -�, /V .'2
ADDRESS ' ' CONNECTION DATA
C[TY TEL. STATION y � {� DEPTH C
❑ STATE MANHOLE REFERENCE
REGISTRATION N0. ❑ COUNTY �l/. I= CY� UPPER 1ZLY•ER
TYPE OF CON SECTIQXh, LENGTH FROM ��' '
No. DESCRIPTION OF WORK FEE Y. CURB P.L.\ M.L.TO P.L.
/ HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q $ 3.50 _��
HOUSE SEWER CONNECTING TO '
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO. IMP. NO. JOB. NO.
WORK TO HOUSE SEWER 1.00 rL
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 100 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL- DRYWELL - WASTE APPROVAL
_ SPECIAL CONDITIONS ONLY 2.00 CHA ES
PERMIT CONNECTION CHARGE FEE /
OWNER'S S 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE /.
TRACTORHAVE TTO CON ECTHIS DATE ONTRTHEA ABOVE DESCRIBED EXISTINGWITH THE HEREIN qMED DWELLING APPRO ALS" DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER -
SIGNED THIS DAY`OF zol�W4�' r 1 NEW HOUSE SEWER
OWNER OR ���f CONNECT ADDITIONAL
OWNERS AGENTc�j_ BUILDING OR WORK
ADDRESS ,-�c��G �y��" SEPTIC TANK, SEEP, PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL[I 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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ROVE ABANDON HOUSE SEWER /
DESCRIBED RESIDENTIAL PROPERTY. ��^^ BACKFILL SEPTIC'TANKS
/ SEEP. PIT(S) ❑ CESSPO
SIGNATUREV
OF PERMITTEE
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION L %
BY _.,:_ -ACO B 3 3' SEP 7 4 4.50
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a: DEPUTY 'DEPUTY
BY BY
® DEPUTY DEPUTT