HomeMy Public PortalAbout9571 LA ROSA DR_Sewer__ DEPARTMENT OF COUNTY ENGINEER, I SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING RESS 7/ �,
ADD � �
FOR APPLICANT TO F LL_IN LOCALITY
BUILDING ���/ ��� � NEAREST /U
ADDRESS /// � CROSS ST
LOCALITY C- I DISTRICT N6. SERIAL NO. PERMIT
NO. c
NEAREST _7
/J 23C1 G D J
CROSS ST / G..
REC IV sBReady for Inspection DAYE ISSU [�
OWNER MAIL ?p �j� 6-�/j -
ADDRESS Ja //�� C—�'�C/(� USE ZO OCCUPANCY M• P
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CITY TEL N0.
CONTRACTOR 4me=N,9
ADDRESS ,/��
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CITY �� TEL NO.0,j ,6.-A,?,jW TRUNK PERMIT NO
STATE
REGISTRATION NO. �� _C Y ROAD PERMIT NO
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO. v+ PERMIT NO
BLOCK TRACT / / INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT _7 -/,3 4.9 NOW ON LOTS CHARG
USE OF ��
BUILDINGS CONNECTION CHARGE F
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
' PUBLICSEWER @ $ 350 RECEIPT NO. DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECQRDED
WORK TO HOUSE SEWER 100
ALTER OR REPAIR EXISTING NO I DATE \ BY
SEWER OR DISPOSAL SYSTEM 100
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR /
PITS AND/OR DRAINFIELD 2.00 STATION Z71 Zt�0,9 DEPTH ;v5—
CESSPOOL—DRYWELL {
SPECIAL CONDITIONS ONLY 200 M FERE NCE
/Q� G UPPEg . EOVMR--
TYPE OFECTION LENGTH FROM
OWNERS PERMIT b 1 cURB � M L TO P L
AUTHORIZATION I TOTAL FEE I `/ (0
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
OWNERS AGENT------_-_------------- _ BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS .-.---- -_--.--_--------- ----- ---_.-_-- ----- ---- --._.. ..---_ AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL[:] DRYWELL❑
CAT
IONAND 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 1 AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS Ej
SEEP PIT(S)E] CESSPOOLS
SIGNATURE /f2 /� &_ u
OF PERMITTEE_______iLC._-- "�!f_.-. :.C "
76A642A 663 7/53 r Q K