HomeMy Public PortalAbout10039 GREEN ST_Sewer__ DEPARTMF,NT OF COUNTY ENGLVEER SEWER—SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I BUILDNG
ADDRESS
FOR APPLICA T TO FILL IN LOCALITY +� -
BUILDING NEAREST
ADDRESS Q •� CROSSST.
LOCALITY DISTRICT NO. SERIAL NO. �PE�RjMIT NO.
NEAREST A � 7 v�� s
CROSS ST.
R@xEI ED BY Ready for Inapeetion 9DATEJ�(SSUED
OWNER
MAIL KESS USE ZONE OCCUPANCY
-ADD
CITY TEL.NO.
CONTRACTOR•:rl. °✓. d401TiWGHW Co, OF SO. M-
CO.IMP.NO.
ADDRESS JOB.NO.
CITY TEL-N0. TRUNK PERMIT NO.
STATE
REGISTRATION NO. ® COUNTY ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. PERMIT NO.
BLOCK TRACTj / INDUSTRIAL
WASTE APPROVAL
SIZE OF LOTNO.OF
�aI NOW ON LOTS C AR S
USE OFf
CONNECTION CHARGE FEE
-BUILDINGS .Ec .
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $ 3.50 RECEIPT NO. D TEI BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION R ORDED
_WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO• DATI\ BY
_SEWER OR DISPOSAL SYSTEM 1.00
DISCO N_AND/OR_ ND DISPOSAL SYSTEM 1.00
SEWER 1,00 CONNECTION D TA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION DEPTH
C E SS P 00 L—DA,YaY.Fler
2.00 M MANHOLEREFERENCEEFERENCE LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ I 1 00
Y. CURB P.L. M.L.TO P.L.
,
AUTHORIZATION I TOTAL FEE a -
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
HAVE
TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS._..__________..DAY OF..___....___.____.________._._19____. NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
BUILDING OR WORK
OWNERS AGENT..........
SEPTIC TANK,SEEP.PIT(S)
ADDRESS...............................................................__..............._........ AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL❑ DRYWELL I]
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE ) "fir
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 DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS E]
ljt kli. SEEP.PIT(S)E] CESSPOOLS
SIGNATURE
OF PERMITTEE............--------------------------------------------- ----------
...
76A642A 663 7/53