HomeMy Public PortalAbout10132 GREEN ST_Sewer__ DEPARTMENT 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 Q _4L., CROSS ST. <<
LOCALITY 1 DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST 1 C A e S
CROSS ST. ,
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER - f < t d i 4MAIL
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ADDRESS ! D/SS _ qty USE ZONE OCCUPANCYMAP
BK PG
CITY
TEL-ND-/C'6' �'G CJ
CONTRACTOR
CO.IMP.NO.
ADDRESS
JOB.NO.
CITY TEL.NO. TRUNK PERMIT NO.
❑ STATE
REGISTRATION NO. ❑ COUNTY ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. 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 REIMBURSEMENT FEE
HOUSE SEWGR CONNECTING TO
PUBLIC SEWER 0 ; 3.50 I RECEIPT NO. I DATE I BY
HOUSE SEWER CONNECTING TO J_
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO. I DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 I CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 I STATION DEPTH
/ CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 I MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS I 00
Y. CURB P.L. M.L.TO P.L-
PERMIT ; �
AUTHORIZATION I 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 PUBLIC SEWER
SIGNED THIS--------------------DAY OF.........................._. 19__..... NEW HOUSE SEWER l-F -1171
OWNER OR _� CONNECT ADDITIONAL
OWNERS AGENT,t _._ at_____ .t____eC':___rf �_ .._1'.K,L_ _ BUILDING OR WORK
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t
SEPTIC TANK,SEEP.PIT(S)
ADDRESS..............._--------------._-_---_._...................... AND/OR DRAINFIELD
CAT ON AND STATE THAT THE ABOVE SVCORRECTTAND AGREIEHIS APPL . CESSPOOL E] DRYWELL
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR L
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❑
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SIGNATURE SEEP.PIT(S)[:] CESSPOOLS
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OF PERMITTEE '�= -- ` 'tea t„• :.':. a_i a a
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