HomeMy Public PortalAbout5761 OAK AVE_Sewer__ DOF COUNTY ENG NEM SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS "GEL=
WILLIAM J FCX COUNTY ENGINEER BUILDING
ADDRESS
R APP LICA TO L IN LOCALITY-
BUILDINQ NEAREST
ADDRESS CROSS ST Q r'
LOCALITY487-1 -
DISTRICT NO SERIAL NO PERMIT NO
NEAREST "� A 11,5
S
CROSS ST
ECEIVED BY Rea&for Ieepeotioa DATE ISSUED
OWNER
MAIL
ADDRESS USE 2 OCCUPANCYBK MAP PG
CITY TEj NO
CONTRACTOR
CO IMP NO
ADDRESS
JOB NO
CITY TEL NO a
TRUNK PERMIT NO
REGISTRATION NO p COUNTY
LEGAL `id 0 ROAD PERMIT NO
DESCRIPTION LOT NOP7. 1 STATE ENCROACHMENT
PERMIT NO
BLOCK TRACT &S'b / INDUSTRIAL
NO OF BLDOS O� WASTE APPROVAL
512E OF LOT�D NOW ON LOT — CHARGES
USE OF
BUILDINGSCONNECTION CRA E
NO DESCRI ION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER a $ 8.50 Cy RECEIPT NO DATE BY
HOUSE SEWER CONNECTING TOJ.
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 100
ALTER OR REPAIR EX15TINO NO DATE 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
CESSPOOL—DRYWELL -�' DEPTH
SPECIAL CONDITIONS ONLY 200 MANPP EFERENCE
TYPECURB ECTION� L L TO P LOM S�
OWNERS PERMIT 1 00
AUTHORIZATION TOTAL FEE 4 ,56
1HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS DAY OF _ .r 19 NEW HOUSE SEWER
OWNER OR - - CONNECT ADDITIONAL
OWNERS AGENT _ _ BUILDING OR WORK
ADORE _ _ _ _ _ _ _ _ _._. — - _ _ AND/Oft DRAINFIELEPTIC TAK SEEPD IT(B)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI CESSPOOL❑ 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
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFOR OR THAT I AM THE LEGAL OWN
ER OF THEA IBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS n
SIGNATURE SEEP PIT(S)[] CESSPOOL$
OF PERMITTEE _ _
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