HomeMy Public PortalAbout10024 LA ROSA DR_Sewer__ DEPARTMENT OF COUNTY ENGUfEER SEWER—SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF:LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS Q O 4-At)-
FOR
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FOR APPLICANT TO FILL IN LOCALITY T
BUILD'NO ,(y ( ' {� s NEAREST
ADDRESS :(J�s• /�j CROSS ST.
LOCALITY r �_ , DISTRICT NO. Reedy for Insuectlon PERMIT NO.
/ f 3 S.� 2-..S
CROSS ST. J-
RECEIVED BY DATE ISSUED
IS�S UpE Dy�BV DATE
OWNER !•Yr �;.f'�1:/��f!�:�•�(i _ / �L //o// 4MAIL �
ADDRESS j i'C'`C�j,"�' Zx o-:5 t USEIONE OCCUPANCY MAP
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CONTRACTOR � tIR+.:Jr�//�f CO.IMP.N0. J3 .2I U�
ADDRESSJOEL NO.
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CITU TEL NO.
-�R�} yam( TRUNK PERMIT NO.
REGISTRATION NO.�elc %V ; ❑ COUNTY
ROAD PERMIT N0.
LEGAL
DESCflIPTION LOT NO. PERMIT NO.ENCROACHMENT
BLOCK TRACT INDUSTRIAL
,/ WASTE APPROVAL
612E OF LOT��Jfj/1 �{i'•`, NOW ON LOT CHARGES
USE OF ✓�
BUILDINGS C..C•,, , ��js'.�e .'Q'-V ry gr CONNECTION MA GE FEE
N0. DESCRIPTION 13F WORK FEE ,
HOUSE SEWER CONNECTING TO .+ REIMBURSEMENT FEE
PUBLIC SEWER ® S 3.50 4 5f' RECEIPT NO. I E' IBY
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00 _
CONNECT ADDITIONAL BLDG.OR XCEPT'ON RECORDED
WORK TO HOUSE SEWER 1.00 __ NO.
ALTER OR REPAIR EXISTING I GATE BY
_ S EWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 1.00 __ CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
_ PITS AND/OR GRAINFIELD RAOSTATION DEPTH
L /
CESSPOOL—DRYWELL 5/ Ca
SPECIAL CONDITIONS ONLY 2.00Gi/ Lam/ - ,, AIA NO t!EyEfERENCE
/ TYPE OF CONNECT>o/ LENGTH FROM /
OWNERS PERMIT $ 1 0D
Y. cufle �iP•L• M.L.TO P.L.
AUTHORIZATION I TOTAL FEE .7
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
CONNECT ADDITIONAL
OWNER OR
fl BUILDING OR WORK
OWNERS AGENT_-. P ,.�.... .._._.__.._.._.._.._.._
SEPTIC TANK.SEEP.PIT(S)
ADDRESS...__..___..._......_.._.._._..._..__._.._._.._..__._.._.................... AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL Q DRYWELL
CATIONAND 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
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND,STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE OE CRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS '
!1 SEEP.PIT(S)Q S
CESSPOOL
SIGNATURE ,
OF PERMITTEE.. ._..L_.._.Ln -
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76A642D S&E 663 4/54
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