HomeMy Public PortalAbout10259 NADINE ST_Sewer__ DEPARTMENT OF COUNTY ENGINEEB , SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COIINTY OF L08 ANG}ELE6 BUILDING
WILLIAM J FOX, COUNTY ENGINEER I ADDRESS
{ f
FOR APPLICANT TO FILL IN LOCALITY
BUILDINGNEAADDRESS GROSS ST
g dCJEt
LOCALITY I DISTRICT NO SERIAL NO PERMIT NO
NEAREST � A Q�W
CROSS ST ' R C VED Ready for Insveetlon DATE ISSUED
OWNER —40
ASS�GMAIL /J
DDREUSE LONE OCCUPANCY
2 S 9' � .�� L [�" o i � / /// PQ
CITY NO
/' I /Virg, �C
CONTRACTOR CO IMP NO
i
ADDRESS JOB NO
CITY TEL NO TRUNK PERMIT NO
STATE
REGISTRATION NO COUNTY ROAD PERMIT NO --'--------�
LEGAL
DESCRIPTION LOT NO STATE ENCROACHMENT f f� PERMIT NO
BLOCK TRACT ��"��� INDUSTRIAL
WASTE APPROVAL
512E OF LOT NO OF BLDGS
NOW ON LOT CHARGES
BUIILDINGS CONNECTION CHARGE FEE
NO DEsiffRipTioN OF WO FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER 4D ; S50 RECEIPT NO ATE SY
HOUSE SEWER CONNECTING TO {
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR EXC 10 ECORDED
WORK TO HOUSE SEWER 100 {
ALTER OR REPAIR EXISTING NO D E BY
SEWER OR DISPOSAL SYSTEM 100
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 100 CONNECTION DATA
SEPTIC TANKSEEPAGE PIT OR
PITS AND/OR DRAINFIELD 200 STATION �S`g" DEPTH �p
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 r /s J MANHOLE REFERENCE
LOWER
TYPE OF CONNECTION
L LENGTH L TO P LOM /^
OWNERS PERMIT ; 1 00
AUTHORIZATION TOTAL FEE 41(S
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS _ _ DAY OF _ _ _ 19 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT _ _ _ _ - _ _ _ _ _ _. _ _ _ _ BUILDING OR WORK
PIC TANEEP
ADDRESS _ _ _ _ _ _ _ _ _ _ _ ANt/OR DRAINFIELD 1T(S)
li 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI CESSPOOL[ DRYWELL
CATION AND STATE THAT THE ABOVE 18 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 I AM THE LEGAL OWN
ER OF THE ABOVE DESCRIB.9 RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS[]
SIGNATURE SEEP PIT(S)E] CESSPOOLS
OF PERMITTE
70A042A 663 7/58