HomeMy Public PortalAbout10685 LORA ST_Sewer__ DEPAIt124ENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDINGn g NEAREST
ADDRESS GROSS GROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST
CROSS ST �. - S
.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER,.
MAIL
ADDRESS - ,,, >l- e< 5USE ZONE OCCUPANCY BK MAP PG
CITY /y TE ''. 3
CONTRACTOR
CO.IMP.NO.
ADDRESS
JOB NO.
CITY TEL „ TRUNK PERMIT N0.
7STATE
REGISTRATION NO-, i � COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT f� ( INDUSTRIAL
(`� NO.OF BLDGS.
SIZE OF LQT WASTE APPROVAL
/�3 NOW ON LOT or CHARGES
USE OF
@UILDINGSZ 4= _3"�fe f J CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER @ $ 3.50 RECEIPT NO. DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO- I DATE I BY
_SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR 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
4;.PFE_ LOWER
TYPE OF CONMECTION LENGTH FROM
CURB`; M.L.TO P.L.
OWNERS PERMIT ; I oo _ =_ — --
AUTHORIZATION I TOTAL FEE — --
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVEDESCRIBED EXISTING
BLIC APPROVALS INSPECTDR'S3[GNATUR£ DATE
SEWED
DWELLING TO 7 PU
SIGNED THIS.. . ,_DAY OF.. 19:-) NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT" e� _ w.. -,'2t /i: i ! BUILDING OR WORK
"xyd r w7 - SEPTIC TANK,SEEP.PIT(S)
ADDRESS-/f.",( 3.....:_-.-.L� /S.- t---.---•-----------------••----... AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL 0 DRYWELL E]
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 REGIST§RED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES CQtJNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA 0 TH AM THE LEGA WN-
ER OF THE ABOVE CRIB IDENTIAL PROPE BACKFILL SEPTIC TANKS(�
SEEP.PIT(S)E:] CESSPOOLS
SIGNATURE
OF PERMITTE -•- .e=-'+ ��
76A642D 663 1/53 i�