HomeMy Public PortalAbout10266 LIVE OAK AVE_Sewer__ . 76AG42D
S E-663 3-55 APPLICATION
PLIC TI N
FOR PERMIT
1
DV ISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL.
Deportment of County Engineer Mimi 1,
• County of Los Angeles BUILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN, SUP'T OF BUILDING LOCALITY
FOR APPLIC NT TO FILL IN NEAREST
CROSS ST,
LEGALe
DESCRIPTION LOT NO. OWNER
BLOCK TRACT . MAIL
ADDRESS u ti-Q_ I-
N 0. O F B L
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. I GROUP I MAP
BK PG
CONTRACTOR D
ADDRESS CONNECTION DATA
CITY TEL. NO. ,+ 9 STATION DEPTH
ATE MANHOLE REFERENCEUPPER
REGISTRATION N0. '�4-0/� ❑ COUNTY -
NO. DESCRIPTION OF WORK FEE
TYPE OF CONNECTIO LENGTH FROM
HOUSE SEWER CONNECTING TO yyyq Y. CURB P.L.j M.L. TO P.L.
PUBLIC SEWER @ $ 3.50 a/ _
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 _
CONNECT ADDITIONAL BLDG. OR P. C. N0.
WORK TO HOUSE SEWER 1.00 CO. IMP. N0. JOB NO.
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK MIT NO. ROAD PERMIT NO. ,
DISCONNECT AND ABANDON SEWER STATE ENCRO MENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/ORDRAINFIELD .00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHAR
$ t o0
OWNER'S
PERMIT CONNECTIO H A RGE FEE
AUTHORIZATION I TOTAL FEE R MBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN AMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTORS SIGNATURE
TO THE PUBLIC SEWER
NEW HOUSE SEWER
SIGNED TH!ls--, G%_DAN' OF
OWNER OR !!! ` CONNECT ADDITIONAL
OWNERS AGENT
_ BUILDING OR WORK
" �- ��-1°
SEPTIC TANK, SEEP, PIT(S)
ADDRESS Z;:�_"2-'4-�'- <l,'c� -'I�'�-r'�✓?• 'x- L�•'•' - AND/OR DRAINFIELD
I0ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL[IDRYWELL C1AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR, SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED1 N I ER,TY., BACKFILL SEPTIC TANKS❑
_ ' r� la^ E . SEEP. PIT(S) ❑ CESSPOOLS❑
SIGNATURE w
1,4 C- - - - '�
OF PERMITTEE
WILLIAM J.FOX, COUNTY ENGINEER VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR
VAR 4.5 0
v r