HomeMy Public PortalAbout4823 HELEO AVE_Sewer__ DEPARTMENT OF COUNTY_•ENGUlUMR SEWER' SEWAGE DISPOSAL
DIVISION OF 'BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOXY COUNTY ENQINEER BUILDI
ADDRESS
FOR APP1qLICA T TO FILL IN LOCALITY
ADDRESS •) Fes/ NEAREST
CROSS ST.
LOCALITY "f DISTRICT NO. q SERIAL NOJ PERMIT NO. C
NEAREST A -�SS
. ' w f/ o
RECEIVED BY Ready for
CROSS STInspection _7/DATE ISSUED
OWNER
MAIL c/ ' USE ZONE OC UPANCY BK PG
MAP
ADDRESS /r` U o-G /y'
CITY TEL.NO.�! I ( " a
CONTRACTOR CO.IMP.N0.
ADDRESS .~�
JOB.NO:
CITY TEL.NO. TRUNK PERMIT NO.STATE
fie®
REGISTRATION NO. H COUNTY
ROAD PERMIT NO.
LEGDESCRAPTION LOT N0. STATE ENCROACHMENT �-
PERMIT NO.
BLOCK TRACT J - 32- WASTE INDUSTRIAL
PROVAL
SIZE OF LOT NO.OF SLOGS. s
t'J .Z ci U NOW ON LOT J CHARGES
USE OF /
BUILDINGS � ': CONNECTION CHARGE FEE �•'
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLICSEWER @ $ 3.50. tS0 RECEIPT NO. > DATE I13Y
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00'
CONNECT ADDITIONAL BLDG.OR EXC!�?TION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNE-TION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD .2.00 : - STATION 37(- �., (py DEPTH 1p
CESSPOOL—DRYWELL / ANEREFERENCE
SPECIAL CONDITIONS ONLY 2.00 / Q
M
t UPPHOLER I
LTYPE OF CONNECT 9N' LENGTH FROM /
OWNERS PERMIT $ i 00 CURB M.L.TO P.L.
✓ P�E"�
AUTHORIZATION TOTAL FEE 5 d
I HAVE THIS DATE CONTRACTED WITH 'THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR' SIGNATURE DATE
DWELLING TO THE PUBLIC SEWE- "
SIGNED THIS.........10........DAY 0F...._ NEW HOUSE SEWER
ICONNECT ADDITIONAL
OWNER OR ij�.�cl BUILDING OR WORK
OWNERS AGENT lb11�1!�1.. ..Gt L- - -. ........---•-- --
SEPTIC TANK,SEEP.PIT(S) '
ADDRESS-----------------------••--•--..........-......_.-_.....................-........ -.. AND/OR DRAINFIELD
CAITHEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL❑ DRYWELL Q'
TION AND STATE THAT-THE'ABOVE IS CORRECT AND AGREE
TO COMP..LY'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
5 SEEP.PIT(S)❑ CESSPOOLS
SIGNATURE ��1�G
OF PERMITTEE---l- ------- r��'--� -••-------------- ----•-•-•-----
7
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