HomeMy Public PortalAbout5609 GRACEWOOD AVE_Sewer__ DEPAICTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
--WILLIAM J. FOX. COUNTY ENGINEER BUILDING '^-
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDINGr NEAREST
ADDRESS " CROSS ST. I v c
LOCALITY DISTRICT NO. A SERIAL NO. PERMIT NO.
NEAREST A -S
CROSS ST.17i
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL USE ZONE OCCUPANCY MAP
ADDRESS I BK PG
CITY TEL.NO.
CONTRACTO CO.IMP.NO.
ADDR
of IF JOB NO.
CI TEL_
_ryl Alft714TRUNK PERMIT NO. --
STATE
REGISTRATION NO. _ 'T —��A— COUNTY ROAD PERMIT NO.
LEGAL 7 STATE ENCROACHMENT
DESCRIPTION LOT NO. PERMIT N0.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT-' NO.OF BLDGS. �,
NOW ON LOT CHARGES
USE OF !
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Ci4 $ 3.50 RECEIPT NO. DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
` CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
t WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO. DATE I BY
SEWER OR DISPOSAL_SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION DEPTH "
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 - 'MANHOLE REFERENCE
lJoiliil (CO W E R
TYPE OF CONNECTI,O.B- LENGTH FROM
OWNERS PERMIT ; 00 ���' P.L. M.L.TO P.L.
-�_-
AUTHORIZATION TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUYLIC SEWER
SIGNED TH[S---------------DAY O . ... ...................IY:,�� NEW HOUSE SEWER ! ,
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT .`n ..---- -BUILDING OR WORK
ADDRESS......... -- -- ------ . ... 04, SEPTIC TANK.SEEP.PIT(S)
------ AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE HAT I HAVE READ THIS APPLI. CESSPOOL E] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE
SEEP.PIT(S)E] CESSPOOLS
OF PERMITTEE...-.....
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