HomeMy Public PortalAbout10249 GREEN ST_Sewer__ / !4e
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76Ae42D APPLICATION FOR PERMIT
COUNTY OF IAS ANGEL FS SEWER-SEWAGE DISPOSAL
DtPARTMENT OF COUNTY ENGINEER
B=ING AND SAFETY DIVISION BUILDIHa Q 2
ADDRESS
WJyTf.T.TA�](_ A. I�• SIIPOt •■7
LOCALITY
N EA R EST
FgAW2F cno■e ST..
DESCRIPTION LOT NO. OWNER
DMAIL �/ `
'LACK TRACT � ADRESS � L
NO. OF BLDS.
SIZE OF LOT I•' HOW ON a
LOT CITY TEL SHO.
USE OF DISTRICT AO.1 GROUP MAP P.
FR ■Y
–BUILDINGS
(7y� I
CONTRACTOR r ,yJ,.
ADDRW C' CONNECTION DATA
CITY TEL. NO. 7 y 7 STATION DEPTH
AT[ MANHOLE R[FXPMNC[ �.q,/
R
EO
'
STRATION NO. COUNTY 7C,J'✓ - LOWER
No. GESCRIPTION OF WORK F[[ TYPE OF CONNECTION LENGTH FOM
HOUSE SEWER CONNECTING TO ��pp Y. CURE M.L.TO F.LR
PUBLIC SEWER $0.00
L r
F.C.NO.
SLPTIC A [ AGE FIT ee 12
(1
FITS AHD/OR DRAINFI[LD 110.00 CO,IMF.NO. JOE NO. <YJ
Hous E S
EWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM 19.00 O(
CONINECT ADDITIONAL■ AFFIDAVIT vZVi [AJEJI[1R RECORD.INSTR.NO. DATE O
WORK TO HOUSE■EWER 11.00
■[E_PAGE PIT,DRAINFIELD
OVER C[S,POOL,DRYW[LL,MA NH OL[
OVERFLOW 18.00 HWY.OR ST.WIDENINGCL
AL R, PA O HDO OU■
SEWER OR DISPOSAL SYSTEM f 7.00 STATE ENCROACHMXNT
PERMIT NO.
INDUSTRIAL
�T�p• WAST[APPROVAL
O��NEaLi S PERNaT s 2 cO CHARGES
CONNECTION CHARON FEE
ADTHORZZATION TOTAL FEE 71 6_8
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- R[1M■URN
SEMET F[[
TRACTOR TO CONNECT THE ABOVE DESCRIBED LXISTING DWELLING
TO.'fH[ PUBLIC SEWER, APPROVAM DAT[ INS 2K
R'll SI TVR[
SIGNED THIS DAY OF f0_
OW N[R OR KEW HOUSE S[W[R
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRIS■
SEPTIC TANK,S[[P,PIT(S)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICR
ATION AND/OR DAINFI[LD
AND STATE THAT THE A■OV[ 19 CORRECT AND AOR[[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CESSPOOL [:3 DRYW ELL ElPLUMSING AND SEWERS.
I HEREBY CERTIFY THAT I AM PROP[R�Y REGISTERED AND/OR ALTER,REPAIR,1[W[R OR
L019LICENSED AS REOUIR[D BY LOANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I TH[ L AL O 11 OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, TH[ DUC ■ RU IAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE I BACKFILL SEPTIC TA.- ❑
OF PERMITTEE SE[P.PIT(■) El CESSPOOL,
ALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
6 2 4 1 ZZ Vjv 2 7 1 0 D 7.0 0— q