HomeMy Public PortalAbout5522 GRACEWOOD AVE_Sewer__ APPLICA ION FOR ERMIT
COMM-OF' Los AN S ER—SEWAGE DISPOSAL
DUAST WNT OF COUNTY ENCS
BUHXMG � SAFETY MISION ND
D t
Mw IL Id1mI>; Co®4T H wh—
C MAA D. Dom• ffWt of LOCALITY
LLTE FOR APPLICANT TO cRD
7,71
DEICQ1Fn0A LOT AD. OWNED
aLDcsTitACT TAIL
ADB
SIZE OF Mt.OF LOT NOW N LOT S.
USE
dF -
BUI4DINOE DISTRICT NO. uP X" oc BT
CONTRACTORto C .
i�
rAl
ADDRM CQ ON DATA
crTT TEL NO. -� f STAnON DEPTH
REGISTt m6iq Nd. �7 COUNT TY aoGs RE C$
NO. Dr-
SSEE g RIP O FEE
PUBLICO RCONN):CT xe TO ar r
�E A g TTFE OF CONVECTION L8 0
PITS 1Ut OR D NFIEtDIT Gtr 41 '.DO T. cu ■. 'I'0 P.L
OTMLn-!SEEPAGE R ELD
ETCH. C L D LI_ 11 OLE 2,00
HOU SEWER Co 11NECTIN0 TO
PRIVATE DISPOSAL ITST ai I.00 CO.IIP.NO_ JOH 110.
CONNECT ADDITIO1{AI��BLDG.OH
WORKTO HOniU(I[PERMIT N0. ROAD PSAKIT X0.
O TI�AUI}SRRE IE�EII I.00
A STBI HOUSE 1.00 9'TA7EENCROACHIPJ"
OR 1) S
PERMIT NO.
VDUITRIAL
AST1:AFPROVA
CHARGES
O PEDUT s 2 60 CONKECCION CHARGE FEE
AUSO=ATION T9TAL FEE 90NBURSE*E*T FES
I RAY!( AT THIS DATE A CONTRACT WITH THE HERffiN RAKED CON, APPHOYAZ3 DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE AHOYR DIEVURIBED EZLSTING DWELLING
TO TKE PUBLIC SEW L
SIGNED THU d►Y OF TA NEW HOUSE SEWER
0�i1ER OR CONNEG'I ADDITIONAL
OWNSEI Aa�'I' BUIL.DI a OR WORK
C "TK,SEEP PFC(I)
ADDRZSS "TOR DRAINFIELD
I HEREST AC[]I0WI�DGR THAT i HAVE READ S APPUCATION _
AND STATE THAT '� )M; lS CORRECT AMD �1GRE$ TO CORPLT CESSPOOL -D2TWELL ri
WITH A1..L ro Lf ORDINANCES AAD STXTE LAWS R$GULAnNG ALTER, IR.SEAR OR
PLUMBING 1L'ND IEWSRs. IE7Ac DISPo9AL 3TITHK
1 MMM CEYTIFT 'CHAT [-AK PRO LT iREG1ST£RED AND/Olt DlaconN PLUG AND
LICENSED REQ UHIRD BT WI ANGELES COONTT AA-0 'STATE OF U�1 ffi
CAUFQ RAIA OR THAT Al T)iE LEGAL 0 OF jHE ASOYE
DESCI;IBED REBID P ? BACRFI7�, C TANKS❑
SEEP.PI ! CESSPOOLS
�,GIUITUR$
OF 4 A Aol—�
mr AYI� ROBERT WOOD
r.
o ..o. SUPERVISING tittc -IAar„cwL,e'[alxKXt
Lr, 4 4 7 2 5 4 1 o n 5.00
DEPARTMENT OF OOVNW ENGlN= SEWER-SEWAGE DISPOSAL 1
,DIVISION OF BUrLDING AND SAFETY PERMIT APPLICATION
r COUNTY OF IGS AN(iEI.E�
WILLIAM J. FOX, COUNT EMBIN[ER AD REISS
FOR APPL1 TO RLL IN LOOALI ,
BUILDING 7' ME
ARE
ADDRESS v1 OROS{{T.
LOCALITY--T?--,0" f> DISTRICT NO. SERIAL M0. PERMIT NO.
NEAREST T a —S
CROSS 8T. RECEIVED BY Ready for lnspwtls■ DATA ISSUED
OWNER
MAIL �? U8EZ E OCCUPANCY MAP
ADDRE88_ �j �i �/J /}e f w�� BK F{
CITY TILR0.
CONTRACTOR ff- CO.INR N0.
ADDRESS / / 11 JOB.NO.
CITY TELN0. lI/ O TRUNK PERMIT N0.
{TUATE
REGISTRATION N0. NTY ROAD PERMIT NO. -41 `� Q
LEGAL
DESCRIPTION LOT N0. /� tL STATE ENCROACHMENT
I PERMIT NO.
BLOCK TRACT 3 / INDUSTRIAL -
WASTE APPROVAL - ` 1 -.s-3
SIZE OF LOT / �' _3 re) NOW ON LCHARGES
Dr
USE OFIfA A-4 CONNECT ARSE FEE
BUILDINGS
M0. DESCRIPTION OF WORK F[[
6 R NNE IN 0 REIMBURSEMENT FE
PUBLIC{EWER &M U RECEIPT NO. TE BY
HOUSE SEWER OONN[ TINS
PRIVATE DISPOSAL SYSTEM 1.60
CONNECT AbOlYlONAL 13LB(L0 EXCEPTION RECORDED
WORK TO HOUSE SEINER 1.01
ALTER OR REPAIR N NO- DATE BY
SEWER OR DISPOSAL SYSTEM IAO
DISWNNECT AND ABANDON SEWER
AND OR D18P08AL SYSTEM LOO CONNECTION DATA
8 AN SEEPAGE PIT OR O
PITS AND OR DRAINFIELD 2{0 STATION - DEPTH
CESSPOOL--0RYW[LL r7
SPECIAL CONDITIONS ONLY L00 M L EFERENCE
E trt�rcn-
TYPE OF CONNEOT7 LENGTH FROM 1
Yr B' P� Y.L.TO P.L
OWNERS PERMIT ; � o0
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
OONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWEQ _
SIGNED THI v Y OF Iq NEW HOUSE SEWER
CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS A
BEPTIO TANKK,SEEP.PIT(4)
ADDRESS AMD/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE BEAD THI APPIJ- CESSPOOL E] DRYWELL E]
CATION AND STATE THAT THE ABOVE IS CORRECT AN AGREE
TO 00MPLY WITH ALL 9OUNTY ORDINAXCES AND STATE LAWSALTER REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS, SFWAdRD
DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED OUNTY DISCONNECT PLUG AND
AND/STAT[ OF011 LICE SOALIFORN AED AS U RETH T D BY I AY THE LE{AL GOWN- ABANDON HOUSESEWER
EQ OF THE A 1) SgmB R ENTIAL P RTY. OT ❑
8EEP.PIT(8)0 CE88POOL8 0
{JGNATURE a
OF PERMI E
T6A64=L 668 T/63