HomeMy Public PortalAbout10065 GREEN ST_Sewer__ DEPA]VrMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING _ NEAREST
ADDRESS CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST A S
CROSS ST.
RECEDED BY Ready for Inspection DA ISSUED
OWNER
OWNER %'--'
ADDMAIUSE ZONE OCCUPANCY MAP
ADDRESS I BK PG
CITY TEL.NO.
CONTRACTOR
CO.IMP.N0.
ADDRESS d �.,
JOB NO.
CITY f TEL.NO. TRUNK PERMIT NO.
❑ STATE
REGISTRATION NO. ❑ COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. STATE ENCROACHMENT
PERMIT NO.
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
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER @ $ 3.50 RECEIPT NO. DATE I BY
HOUSE SEWER CONNECTING TO
_PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLD6.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER eR REPAIR EXISTING NO. I DATE 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/ORDRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ I 00 Y. CURB P.L. M.L.TO P.L.
AUTHORIZATION TOTAL FEE �5
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THE PUBLIC SEWER APPROVALS INSPECTOR'S SIGNATURE DATE
SIGNED THIS-,..................DAY OF........................................19..._... NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT.......----......-......-..........--•----......................-......... B U I L D I NG OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS-----------..._.__..._____________________________-•-------••-•--------_--_....__.--_-• AND/ORDRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL❑ 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
I 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 DESCRIBEQ RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGSEEP.PIT(S)o CESSPOOLS
❑
OF PE
URE -
�,
RMITTEE-Y _._-. ..----• ---•---------•---°�+�-------•--_-------------------
76A642D 663 1/53
7aAe,zo
CE
(WV. APPLIC ION ,FO PERMIT . . ,
,
m, ,
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANG&M BUILDING AND SAFETY
FOR APPLICANT TO FILL IN [)M RICTKO: �ICNECTION
MAF pa �
DATA
LOCALr Y
GROSS ST.
MANHOLE REI7RENCa
OWNER
TYPE OF CONNECTK)N LENQfFi FROM' -
AKAJL
DDRILSS Y. CURS F Y1 TO F.L
F.C,NO.
GO. .NO. Joe NO. '
CIT' TEL NO.
meatia� TRUNK Pa RM IT NO. ROAD re nmrr NO.
DOSC1kPTION LOT NO. J
TRACT
Z� AJ<FIDAHIT W EAaC1LEMT FIiGORD.IFf1-fR t+0. DATE
BLOCK
NO.of eLpae.
DPM OR NOW ON LOT HWM.OR ST.WIDENLNO
UN�' STATE ENC ROACH Y■NT
eju
FSR r rr No.
I USTRIAL
CONTRACTOR �ASTa ArFROVAL
ADDRKVp
CHARGES
CITY TEL N go
CWWKcTKN+CHARGE PEE
STATE LJG. RE■I e U RS G M E NT Fa I
LJCXNSE NO.
Dese I ION Or WORK Flt APPROVALS DATE INBreCTo R'S SIa NAru
FFOUSE SSMIaR CONNECTING TO IIle
FsarITCTArnciavwaaFrrow NEwHOUSEIEWER
FLTS AND/OR DRAUM KLD CONNECT ADO ITYONAI_
HOUSE SEWER GOND TO DU RD Rib OR WORK
Ih "NATE DAPOSAL qYSTll Y
SND/O TANK■EEL. IT1.
F8)
CONNECT ADDITIONLDa.
AL■ OR AND/OR DRAIN FlaLD '
WORK TO HOUSE ENVY"
OVa RFL.OW BE SPAS PIT,DRAINFIELD CESSPOOL ❑ DRYWELL❑
KxrK.CESSPOOL,DRYWELJ,MANHOLE
ALTER,REPAIR OR AlFANDOH HOUSE ALTER.REPAIR.SEVER OR
■aWaRO DLSlOSALSYSTEY SiWAO■D LSPOSAL SYSTEM -
._ DISCOWECT PLUG AND
N
AJ ANDOHOUSE SEWN
MAC KIP ILL SETTIC TANKS Q - -
.•
OWNER'S---] Permit SE■P.Prris)❑ Cass FOOD Ela
AUTHORIfAno TOTAL FlitYDATION
I HAW-AT-THIS.DATK-A CONTRACT WITH TWE HERE W kAM ED LON- -. -
TOT n UT CMLICSR TH■ a DaSGlUeaD�USTRIa DMIELLfNa j, - _(Q{ 3 2 0 fl
TOT
-D r -Ip v C o a.o;o 1 0.
OWNEROR
owNLLRi Aa 2O""O 1-800
ADDltilb AC
A70 STATI•Y TTHA STH E AD�QVE LS CORRECT A�tiD AGREE TO GOYF3Y O O &THIS ArPLJCAT�ON 6 O .
WITH ALL AC"JNTY ORDINANCES AND STATE LAWS Ra6ULATLNO
PL 1YHEREBY C RTLI-Y THg 1 PROra7+LY Ra0[STE RSD A{+U/OR _ - 0 •�' _��
LJCSNSKD AS RfCALJFORNLA T#Q{/U�IR1D by LL�.�6 A1i00EWLiyS COUNTY AND STATE OF
QW
a IH.THE ASOVI T[SaYCRi■ED RSS LDaNhALFNO AIM LN3ETID TO Ra-
Sq NATURE - - -
OF FERII ITTE