HomeMy Public PortalAbout8902 LONGDEN AVE_Sewer__ E-669 12•54
B of E•a8''7a APPLICATION. FOR PERMIT ]�
DIVISION OF BUILDING AND SAFETY SEWER SEWAGE DISPOSAL
Department of County Engiaeer
County of LOS Ansi BUILDING O
WM.J. FOX, COUNTY ENGINEER ADDRESS
` CASSATT D. GRIFFIN,SUPT OR BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT - v MAIL
/ J \ ADDRESS
SIZE OF LO �P / i 1 NOWOONBLOTS \ CITY TEL. NO
USE DI i7Z9
BUILDINGS `CSi.J CO. DISTRICT NO. GROUP MAP
CONTRACTOR CALF.SEWER CONST.CBK PG
6' M
ADDRESS 1317 COLEGROVE AVE. CONNECTION DATA
CITY MONTEBELLO TEL. NOPA. 1-5048 STATION Cir f/ 0 DEPTH '�• �
A C [� ❑ STATE ! /MANN EREFERENCE EEESSS
REGISTRATION NO. 14865 J (STATE) ❑ COUNTY e �A16 UPPER
TYPE OF CONN VCT LENGTH FROM -�
NO. DESCRIPTION OF WORK FEE Y. CURB P L. M L TOP L
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q $ 3 50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00 / fj
CONNECT ADDITIONAL BLDG. OR CO. IMP. N0. ! ✓ JOB. NO
_ ORI(TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING �7 . �•�
--SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCR04CHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK, SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 RGES
CONNECTION CHARGE FE
OWNER'S PERMIT S 1 00
AUTHORIZATION TOTAL FEE _ REIMBURSEMENT EE
TRACTORHAVE TTO CONNECT THEHIS DATE AABOVE DESCRIBED EXISTINGCTED WITH THE HEREIN ADWELLIING APPROVALS DATE INSPECTOR•SSIGNATURE
TO THE PUBLIC S WER
SIGNED THIS AY OF NEW HOUSE SEWER i
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT Ay.., BUILDING OR WORK
SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL ElDRYWELL❑
AND 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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND'-
LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROP RTY. BACKFILL S6PTF9-Ti�#R9'I]
SIGNATURE p
S CESSPOOLS
�
OF PERM ITTE -
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
BY _.�l�,o BY6 7 3i--) SEP 8 4 4.50
(n
DEPUTY DEP
��UTY
BY BY
0 DEPUTY DEPUTY