HomeMy Public PortalAbout10055 LA ROSA DR_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 A
I DMITNG
ADDRESS
FOR FVA
O FILL IN LOCALITY ! �
BUILDING ' �T1-.��.��/$�Q CNEAREST
ROSS ST.
ADDRESS ll
LOCALITYDISTRICT NO. SERIAL NO. PERMIT NO.
cRosssi. �W !?— 'O` `, RECEIVED BY Ready for Inspection DATEISSUED
OWNER IA S Y� 15 k\MAIL
.
ADDRESS �. ���/ USE ZONEI OCCU� BK MAP PG
CITY "5 � TELA
O.TELO. o
CONTRACTOR P,'\rtIr i'\y, l<O1/(\
CO.IMP.N0. 3
ADDRESS "'�)A )OB.NO.
CITY �y�l �'1 X11`�'1TELAO. �d F�-�\may rj TRUNK PERMIT NO.STATE
REGISTRATIONNO. ❑pCOUNTY /
ROAD PERMIT NO.
LEGAL ^ STATE ENCROACHMENT /
DESCRIPTION LOT N0. 1 PERMIT NO.
BLOCK '� TRACT l� �a \ WpSTTARIAL VAL
SIZE OF LOT G �� ( NO.OF BLDGS.
C1 NOW ON LOT CHARGE
USEOF
DI ��rrJJ CONNECTION CHARGE FEE
BUILDINGS IG', r_ /'
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE /
HOUSE SEWER CONNECTING TO
PUBLICSEWER $ 3.50 RECEIPT NO. I/ DATE IBY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 _
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED\
WORK TO HOUSE S EWER 1.00 ov �:"
ALTER OR REPAIR EXISTING - DATE BY
SEWER OR DISPOSAL SYSTEM 1.00 1
DISCONNECT ANO ARA NUON SEWER
ANO/OR DISPOSAL BY M 1.00 CONNECTION DATA
SEPTIC TANK.SEEPAGE PIT OR
_ PITS AND/OR ORAINFIELO_ --^^s" 2.00 STATION / DEPTH
CESSPOOL—DRYWELL'-
SPECIAL CONDITIONS ONLY 2.00 / MANHOLE REFERENCE
UPPER LOWER
TYPE.OF CONNECTION LENGTH FROM
OWNERS PERMIT $ ( I DD Y, f CURB P.L. M.L.TO P.L.
AUTHORIZATION I TOTAL FEE I �) t)/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
OWNER OR CONNECT ADDITIONAL ' /x22
OWNERS AGENT.: _......... BUILDING OR WORK (L/.Letd/, f� i!-,
-- -- - SEPTIC TANK.SEEP.PIT(S)
ADDRESS____----_....._._.....-------..........._..._............_........._........._... AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI. CESSPOOL[] DRYWELL I]
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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
ANO/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN. ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS El
I 0 SEEP.PIT(S)[j CESSPOOLS
SIGNATURE P ERMITTEE_LAA
O `�
76A642D 663 1A,3