HomeMy Public PortalAbout10017 GREEN ST_Sewer__ :7
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7eAe�sD APPLICATION FOR; PERMIT
COUNTY OF LOS ANGELES ' SEWER-SEWAGE DISPOSAL �J
DtPAHTII�NT OF COUNTY ENGUCE:ER
BUILDING AND SAFETY DIVISION BUILDING
ADDRIIf � A
LDCALi TY
HEA REST
FOR APPLICANT TO FILL IN " ■T
PLI
74
DESCRIPTION LOT NO. ON'N[R
MAIL
BLOCK TRACT AD-IL. _
NO. OF ■LDGS. '
SIZE OF LOT NOW ON LOT CITY L. NO.
USE OF DISTRICT NJ GROUP MAPPR OC[SSED Y
BUILDINGS
■K PO t
CONTRACTOR
ADDRESS CTI N DATA
STATION D
CITY T[l. HO
MANHOLE R[F[RENCE J I=WNR R
REGISTRATION NO.
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION .L LENGTH RR
HOU■[i[W LR CONN[CTI NO TO Y. CURS M.L.TO P.L_
PU■LIC B[WLR •8.00 may,
StPt IC TANK.■ROE P JONO. TT y O
PITS AND/OR DAINFIELD 510.00 CO.IMF.NO.
HOUSE■[Wilt CONNECTING TO TRUNK PERMIT NO. ROAD I'XXMrT NO.
PRIVATE DISPOSAL SYSTEM S?.00 JIM
CONNECT ADO TIONAL■ AFFIDAVIT •Anq WD[11T RECORD.IN■TR.NO. DATE O
WORK TO HODS[■EWER [7.00
OVERFLOW SE EPAOE PIT,DRAINFIELD
J:XTll..CL■FOOL,DRYWELL,MANHOLE f $0.00I L�
AL AIR O DO HWY.OR ST.WIDENING } {/�
SEWER OR DISPOSAL SYSTEM 7.00 STAT[ENCROACHMENTdp Z
PERMIT NO.
INDUSTRIAL
WAST[APPROVAL '
CHARGES
PERMIT s x Oo
AUTHORTLAnON TOTAL CONNECTION CHARD[F[[
r
1 HAVE AT THIS DATE A CONTRACT WITR THE HEREIN NAMED CON- R[IMBURT SEMEHFEE
TRACTOR TO CONNECT THE ASOV[ D[SCRIEtD [)SISTIHO DW LLLINO
TO THE PUBLIC SEWER. AMOVAIS DAT[ IN■P GTQR'S SIGNATURE C
SIGNED THIS DAY OF
OWNER OR NEW HOUSE SEWER 1
OWNERS AGENT CONNECT ADDITIONAL .{+�
BUILDING OR WORK
ADDRESS ■EPIC TANK.SEEP.PIT(a)
I HEREBY ACKNOWL[Db[ THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AHD STATIC THAT THEASOVE ie CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATIC LAWS REGULATING
FLU MING AND SEWERS. CESSPOOL ❑ DRY-WILL ❑
1 HERESY CERTIFY THAT I AM PROPERLY REGISTER ED AND/OR ALTER,REER
PAIR,SWEOR
LICENSED AS REQUIRED BY AN
ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ASO CRI R [ L OPE ABANDON HOUSE SEWER
SIGNATURE BACKFILL■[PLC TAN" ElOF P[ItMI SEil.PITS) Lf CESSPOOLS
VALIDATION ROBERT WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.0.
GA1H
v
0 5 8 6 MAR 18 1 0 0 7,Q O N
I
f
DEPAIC32M NT OF COUNTY ENGIN ER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
OOUNTY OF IAS ANGELIINBUILDING U I L D 18
WILLIAM J. FOX, COUNTY ENM [[R E
x
FOR APPU T TO FILL IN LOCALITY
BUILDINGNEAREST
ADDRESS CROSS ST.
LOCALITY o DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST p A U
CR088 ST. 8 CEI D BY Ready fir lommuo■ DATE ISSUED
OWNER r SrC`
MAIL U EZOIIE OCCUPANCY �MAcP V
ADDRESS Gam' /
i 'DK PO
CITY T¢LNO.
CONTRACTOR CO.IMP.N0.
ADDRE88 ` p JOB NO.
CITY T¢LNO. — L '2;t 3 TRUNK PERMIT NO.
ATE
REGISTRATION NO. COUNTY ROAD PERMIT NO.
LEGAL i ' ' STATEENCROACHME
DE80 I 10
PERMIT N0.
0 TRACT IHDUBTRIAL
WASTE APPROVAL
SIZE OF LOT ,q `/` +� N0.OF BLD88
f zy 1Cf ! NOW ON LOT CHA
UBE OF
BUILDINGS ( CONNECTION CHARGE FEE
NO. DESCRIFTION OF WORK FEE REIMBURSEMENT F¢¢
HOUBE SEWER C;ONNE=NQ TO
PUB LIO SEWER us RECEIPT N0. ATH BY
B E CON k k OT
PRIVATE DISPOSAL SYSTEM I.M
56NN9CT ADDITIONAl BLOILR EXCEPTION RHOED
WORK TO HOUSE SEWER I."
A E N NO DATE BY
SEWER OR DISPOSAL SYSTEM IAO
DISCONNECY AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DAT
&EPTIO TANK.SEEPAGE T ON
PITS AMB OR DRAINFIELD 2XG STATION �j DEPTH
cess L
SPECIAL CONDITIONS ONLY 2.06 MANHOLE REFERENCE
-AH'P!$ LO WE R
r
NNECTION-`- —zCE'NGTj1 Fk�I�
16
OWNERS PERMIT $ I DCP.L Y.L TO PalAUTHORI ATION TOTAL FEEI HAVE THIS DAT¢ CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINGALS INiPEOT&risle �ktUgE' OTE
DWELLING TO THE PUBUO SEWER
SIGNED Tms t OF 19,S NEW HOUSE SEWER
OWNER OR CONNECT AbbITIOltAL
OWNERS AOENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT($)
AMD/OR DRA NFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI• CESSPOOL DRYWELL
CATION AND STATE THAT THE ABOVE Ii CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAID,SEWER OR
REGULATING PLUMBING AND SEWER$. SEWAdE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT LUQ AND
AND/OR LICENSED A8 REQUIRED BY LOS AMGfiLHi COUNTY
AND STATE OF CALIFORNIA OR THAT I A THE L"AL OWN. ABANDON HOUSE SEWER
EB OF THE ABOVE D D REsJ ALP PfiQTY. F TAM ❑
SIGNATURE ` Q 0 f) SEEP.PIT(S)E] CESSP00La�
OF PERMITTIEN
T6A04L 60 T/62