HomeMy Public PortalAbout10212 NADINE ST_Sewer__ DEPA$T9�NT OF COUNTY ENOINE>LB
SEWER—SEWAGE DISPOSAL 1 Q 311
DMSION OF BUnM NG AND SAFETY PERMIT APPLICATION
�t COUNTY OF 1,08 ANGELES
WILLIAM J FOX. CauNTY ENUINKER BUILDING
ADDRESS
FOR APPLI T TO FILL IN LOCALITY
BUILDING NEAREST
ADDRESS CROSS ST
LOCALITY DISTRICT NO SERIAL NO PERMIT NO
5 A
CROSS 8T .aA . O
EOXIVED Readyfor IosOesUoa DATE ISSUED
OWNER
MAIL
ADDRESS USE ZONE OCCUPANCY SK MAP PG
CITY TEL.NO I
CONTRACTOR CBlil OPniA Sewer COnat_(le_ Co IMP NO
ADDRESS 1317 Colegrove Ave. JOB No
CITY Montebello TEL NOUNlOn 1-5n48 TRUNK PERMIT NO
REGISTRATION NO 104448 STATE
GZ�. I� S NTY ROAD PERMIT NO
DESCRIPTION LOT NO p STATE ENCROACHMENT
rp PERMIT NO
BLOCK TRACT�V O WASTE APPROVAL
SIZE OF LOT,6- NOW ON LOTS CHARGES
USE OF
BUILDINGS CONNECTION CHARGE F E
NO DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER O $ 350 RECEIPT NO A BY
HOUSE SEWER CONNECTING TO '
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR EXCEPTIO ECORDED
WORK TO HOUSE SEWER 100 NO DATE BY
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM lee
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 100 CONNECTION DATA
SEPTIC TANK SEEPAGE PIT OR +t^
PITS AND/OR DRAINFIELD 200 STATION I 0 -
DEPTH
CESSPOOL—DRYWELL _
SPECIAL CONDITIONS ONLY 200 NUPPEREFERENCE NSR
PE OF CCONS E ION... LENGTH OPFL FROM
OWNERS PERMIT $ I I 00 INNIrP I.)
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED I
CONTRACTOR TO CONNECT THE ABOVE DESC IBED EXISTING APPROVALS INSPECTOR 8 SIGNATURE DATE
DWELLING TOTE PUBLIC SEWER
SIGNED THIS DAY OF _ _ (y,f3 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AG Pi-i
_ _ _ _ _ BUILDING OR WORK
ADDRESS Q9t'r_ AND%OR DRAINFIELD IT(8)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ T1411CAPPLI CESSPOOL[3 ORYWELL
CATION AND STATE THAT THE ABOVE 18 CORRECT AND AGREE 13
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSALSYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUS AND
AND/STATE OFBCALIFORNIAUOR THAT 1 AM THE LEGALOOWN ABANDON HOUSE SEWER
ER OF THE ABOVE
� \DESC BED SIDENTIAL PROPERTY BACKFILL SEPTI TANKS
SIGNATURE / / J SEEP PIT(S)0 CESSPOOLS
OF PERMITTEE • _� • _ _
IGA632D 60 1/68 _