HomeMy Public PortalAbout10674 LORA ST_Sewer__ nEFART MWFF%*MgW Ext�}n�T = SEWER—SEWAGE DISPOSAL 1 `
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COW= OF X09 "GEL=
WILLIAM J. FOX. COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO LL IN LOCALITY
BUILDING �� 7L P� ' w ' r NEAREST eI ''yam
ADDRESS `7" �4GL� /l_ NEAREST. GLX/ O/I
LOCALITY DISTRICiNO. Ready for Inspection PERMIT N0.
NEAREST
CROSS ST. ECEIV BY ADATE I ISSUED BY q .2!9DATE
MAIL D -Gam(,./ /V 'S
ADDRESS / USE ZONE OCCUPANCY BK MAP PO
1
CITY TEL.BO 5
CONTRACTOR / 3 a / 3
CO.IMP.N0.
ADDRESS
JOB.N0.
CITY TEL.NO. TRUNK PERMIT NO.
REGISTRATION 1111. B COUNTY ROAD PERMIT NO.
LEGAL (
DE8CRIPTION LOT N0. ( STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT /a g INDUSTRIAL
WASTE APPROVAL
SIZE OF LOTyy I +� NO.OF BLDG8. CI —
'1 NOW ON LOT CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER as S.SO RECEIPT NO. I DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00 D O
ALTER OR REPAIR EXISTING NO. I DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
_ AND/0R DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ 1 OG Y. CURB P.L. M.L.TO P.L.
AUTHORIZATION I TOTAL FEE oZ D
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO . P ELIC $EWER _
SIGNED THIS • DAY OF . Iq NEW HOUSE SEWER
CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT _yy.. .. _ . ... _�_._
ADDRESS.-/�.. ,._.rL.. _.. ,f._... SEPTIC TANK,SEEP.PIT(S)
.L... AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL[] 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 1 AM THE LEGAL OWN.
ER. OF THE ABOVE D RIBED RESIDENTIA PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE SEEP.PIT(S)[] CESSPOOLS[]
OF PERMITTEE...
7GA642D S&E 663 4/64