HomeMy Public PortalAbout10203 NADINE ST_Sewer__ DEPASTbIENT OF OOUNTY ENGENEM 1 SEWER—SEWAGE DISPOSAL 1
�j DIVISION OF BUMDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS "GELEB
WILLIAM J FOX, COUNTY ENGINEER ADDRESS OLd�3 E /�E
FOR APPLICANT TO FILL IN LOCALITY
BUILDING w� r �/ �+ NEAREST
Qe��iC7
ADDRESS � G, /J�i�� ,r 07T CROSS ST
LOCALITY *k SERIAL DISTRICT NO SERIAL NO PERMIT NO
NEAREST + S A s
CROSS ST
/� , RECEIVED Y Ready for IBspsedaa ISS
OWNER �I/�� �/J9 f' LQ/�///4/�, 114;7.7;7s:3
ADDRESS /D,7O.r � �/�®y'4"co2/ U8EZON OCCUPANCY
CITY / FAV,01, e' eVArnEL NO 9_/
7
CONTRACTOR ideoW CO IMP NO
ADDRESS v'�41Gts �doomeE' 06, JOB NO
CITY TEL NO egg ry� � TRUNK PERMIT NO
AI I' STATE
REGISTRATION NO 7/ !� [COUNTY ROAD PERMIT NO
LEGALSTATE ENCROACHMENT
DESCRIPTION LOT NO c PERMIT NO
BLOCK TRACT /-S1620 2 1NA8TE APPROVAL
SIZE OF LOT X /.2V NOO OF W ON LOTS CHARGES
USE OFv. CONNECTION CH GE FEE
BUILDINGS Aam
NO DESCRIPTION OF WORK FEE REIMBURSEMENT F
PUBLICBSEWERCONNECTIN TO $50 3 RECEIPT NO DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 188
CONNECT ADDITIONAL BLDG OR XCE ON RECORDED
WORK TO HOUSE SEWER 188 0
ALTER OR PAIR EXISTING ATE BY
RE
SEWER OR DISPOSAL SYSTEM 1004/0
AN/D ORNDI8PD8AL SYSTEM SEWER 180 CONNECTION DATA
SEPTIC TANK S EPAGE PIT R
PITS AND/OR DRAINFIELD 2A0 STATION I DEPTH
CESSPOOL^-DRYWELL
SPECIAL CONDITIONS ONLY 2803 75' AN PP FERENCE +�.L+OW
. 1fPE OF=ECTI P LENGTH
EL T FRO L OM it
OWNERS PERMIT : I 00 �+
AUTHORIZATION I TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS IN8PECTOWSSIGNAT RE DATE
DWELLING TO THE PUFLIC SEWER
516NED THIS ,�d _D Y F_ 19" NEW HOUSE SEWER
• CONNECT ADDITIONAL
OWNERS OR
� BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS/VA f _0?1 IL AND/ORDRAINFIELD
1 HEREBY ACKNOWLEDGE T AT 1 HAVE REAS THIS APPLI CESSPOOL[3 DRYWELL 13
CATION AND STATE THAT THE RBOVE 18 CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND OR
OF CALIFOREQUIRED
NIAUOR THAT 1 AM THE LEGAL OWN ABANDON HOUSE SEWER
ER OF THE ABOV "RIB TIA�20!7 -
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BACKFILL SEPTIC TANKS
SIGNATURE SEEP PIT(S)[] CESSPOOL a
OF PERMITTEE _
888 1/53 �� �i