HomeMy Public PortalAbout10879 GRAND AVE_Sewer__ 7aA"= APPLICATION TOR PERMIT
i 06DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE D 1 S POSA L
of Cotmtr
_ Co=t7 of Los Angt+lr FL�O_E"'
LDING
WM.J. FOX, COUNTY ENOINB:BSt
DRESS
CAEIATT D. GRIMM, SLWT OF YUH-DING ALrrr
F
OR APPLICANT TO FILL IN COU 3T.
N LOT X0. �NLW
TRACT MAIL
ADDRE"
N0. OF BLDG3.
T NOW ON LOT CITY NO.
BUILDINGS DISTRI�O. GROUP
I YAP
CONTRACTOR K G
CONNECTION DATA
[REGISTRATION
Y TEL. N0. i-J STATION DEPTH
GTATE —jA EFERENCE
NO. ❑ COUNTY LOWER
TYPE OF CONNECT! LENGTH F-ROYDESCRIPTION OF WORK FEET. CURB P Y.L.TO P.L.
HOU BE SEVER CONNECTING TO L;
PUBLIC SEWER 0 4 3.90 �J
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL GYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO. IMP.NO. �j JOS. NO.
WORK TOLHOUSESEWER 1.00
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.90 TRUNK PERMIT NO. ROAD PERMIT NO.
C DISCONNECT AND ABANDON S"FR ATS ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 STATE
NO.
SEFTIC TANK, SEEPAGE PIT OR INDUSTRIAL
PITS AND/OR DRAINFIELD 2.010
CESSPOOL-DRY-WELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHAEGp
CONNECTION CHARGE FEE
OVPNEH'S PMUT $ 1 00
AUTEORIZATION TOTAL FEE REIMBURSEMENT FEE _
TRACTORHAVtTO CONNECT THE ABOVE DESCR BEDHUIESTIN9ARlYEI L MCCON APPEOVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIR /}} SAYQ(�F 19- NEW Houee SEWER
OWNER-" OR �l / CONNECT ADDITIONAL
OWNERS AGENT��4� BUILDING OR WORK
SEPTIC TANK,SEEP, PIT($) -
ADDROS AMD/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAYS READ THIS APPLICA7'f0N CE98POOL❑ DRYWELLL7
AND
STATE THAT THE ABOVR If CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR SHYER OR
PLUMBING AND SEWERS. SEWAGE DISPOiiI_SY3TE*
1 HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LO ANGELES COUNTY AND STATS OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LZGAL OWNER OF THE ABOVE ASANDOR HOUSEBEWSR
QESCRIBED REBIDKXTIAL PROPERV. BACKFILL C YKS
S£IP: Tfll Ll
f
SIGNATURE
OF PERMITTEE -
w11 r tau J.Fox.CouNTY Lr1GLNBxjt VALIDAIION / ea.
ArT My 410-A.
DEPUTY D EPP M
�.
--.02 4 9 ON NOV 19 4 4 5 0 E1
R By
m D"M DEPUTY