HomeMy Public PortalAbout5335 NOEL DR_Sewer__ D
Sam6APPLICATION FOR PERMIT 1
s s a DNMON OF BUUMBiG AND SAFETY SEWER-SEWAGE DISPOSAL
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WM J FOX COUNTY ENGINEER
CMEIATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FM IN CNEAREST OF
ROSS ST6011-
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK je TRACTNO OF MAIL
ADDRESS
3 �12E OF L0 1' /�O NOW ON LOTS CITYe.,011. NO Q 8'
USE OF
BUILDIN Jg" DISTRICT Ov� BK MAP PG
CONTRACTOR v y
ADDRESS CONNECTION DATA
CITY l TEL NO o rl STATION DEPTH
❑ STATE MANHOLE REFERENCE UPPER
REGISTRATION NO ❑ COUNTY LOWER
NO DESCRIPTION OF WORK FEE a"Al ;;- /too OF
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER S 350 Y CURB P L N L 70 P L
HOUSE SEWER CONNECTING TO '
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR / 10 P C NO
WORK TO HOUSE SEWER too 1 CO IMP NO JOB NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 100 TRUNK PERMIT NO ROAD P NIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 100 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 200 INDUSTRIAL
CESSPOOL DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 200 HARGES
Owm s PER= CONNECTION CHA FEE
S 1 00
AUTHORIZATION I TOTAL FEE 10 a REIMBURSEMENT FEE
IHAVETRACTOR7TO CONNECT OIN
THEHIS DATE AABOVE CTED WDESCR BED EXITH THE ISTING DWELIN NAMED LII APPROVALS DATE IN PECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM LEGAL R F THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL P TY BACKFILL SEPTIC TANKS❑
SEEP PITS CESSPOOLS
SIGNATURE
OF PERMITTEE
WILLIAM J FOX COUNTY ENGINI[Zlf Z VACATION R A WOOD CHIEF PLUG INSPECTOR
:A60AlZlR MY30 4 200 11)
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