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HomeMy Public PortalAbout9569 LA ROSA DR_Sewer__ DEPAR'r3fENT OF COUNTY ENGINEERSE�/Ela—SEVVe�►CE DISPOSAL DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION COUNTY OF LOS ANGELES BUILDING I WILLIAM J. FOX, COUNTY ENGINEER I ADDRESS i FOR APPLICANT TO FILL IN LOCALITY BUILDING ^� r `C� � (;1 NEAREST ADDRESS VJ / CROSS ST LOCALITY DISTRICT A SERIAL N0. PERMIT rc NEAREST f1 �J J CROSS ST­� ty RE IVED BY Ready for Inspection ATE ISSUED OWNER C ''j �� ;�� ADDRESS �� C -C- - Ce�.� !/UGSEZONE OCCUPANCY ' RKJOWR PG T CITY TEL.NO. �/ CONTRACTOR 68 P�kP:iYA C� . 7 7 ADDRESS JOB NO S� 7 CITY TEL NO. dC/[�0 G_g� TRUNK PERMIT NO STATE REGISTRATION NO 11.5VICI3 �� / e;COUNTY' ROAD PERMIT NO LEGAL / STATE ENCROACHMENT DESCRIPTION LOT N0. PERMIT NO BLOCK TRACT / 93/ INDUSTRIAL WASTE APPROVAL SIZE OF LOTs7 X / NO OF BLDGS CHARGE 3 0 NOW ON LOT 'USE OF \ BUILDINGS ( _ CONNECTION CHARGE FEE NO. DESCRIP ION OF WORK FEE !ad_/ REIMBURSEMENT FEE HOUSE SEWER CONNECTING TO PUBLICSEWER a $ 3.50 �� � � RECEIPT NO. �I/ �D`E BY HOUSE SEWER CONNECTING TO `� PRIVATE DISPOSAL SYSTEM 1 00 CONNECT ADDITIONAL BLDG.OR /EXCEPTION RECORDED WORK TO HOUSE SEWER 1 00 /NO I DATE `\ I BY ALTER OR REPAIR EXISTING __ - SEWER OR DISPOSAL SYSTEM 1 00 DISCONNECT AND ABANDON SEWER _ AND/OR DISPOSAL SYSTEM 100 CONNECTION DATA SEPTIC TANK,SEEPAGE PIT OR t PITS AND/OR DRAINFIELD 2.00 STATION 7♦ DEPTH r CESSPOOL—DRYWELL SPECIAL CONDITIONS ONLY 2007- 61ANHOLE`REFERENCE LOWER- -TYPE OFC ,NNECT10 LENGTH FROM OWNERS PERMIT $ I pp ItP L,' M L TO P L AUTHORIZATION TOTAL FEE d-0 G' IHAVE 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 NEW HOUSE SEWER SG 4� fL OWNER OR CONNECT ADDITIONAL OWNERS AGENT----------------- BUILDING OR WORK SEPTIC TANK,SEEP.PIT(S) ADDRESS -_- ___- .------------------------ ------------------- -•-------------- AND/OR D RA 1 N F I E L D I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI• CESSPOOL 0 DRYWELL 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 I 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 SEEP.PIT(S)E] CESSPOOLS SIGNATURE O_-., - -� OF PERMITTEE..__. _.�-_._ _______ •. 76A642A 663 7/53 ©�