HomeMy Public PortalAbout6303 OAK AVE_Sewer__ DEPAUTTAENT OF COUNTY ENGINEER SEWER--SEWAGE DISPOSAL
r DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING NEAREST
ADDRESS CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST A S
CROSS ST.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL
ADDRESS USE ZONE I OCCUPANCY BK MAP PG
CITY TEL.NO.
CONTRACTOR CO.IMP.NO. _
ADDRESS F-Y
10B NO.
CITY TEL.NO.
TRUNK PERMIT NO.
STATE
REGISTRATION NO. COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT INDUSTRIAL
SIZE OF LOT NO.OF BLDGS. WASTE APPROVAL
NOW ON LOT CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER $ 3.50 _ RECEIPT NO. DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO- ( DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION DEPTH
_I CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPRV! LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT i Y. CURB P M.L.TO P.L. _
AUTHORIZATION I TOTAL FEE _
1 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
SEPTIC TANK,SEEP.PIT(S)
ADDRESS........ - ................. AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THATA HAVE READ THIS APPLI- CESSPOOL 0 DRYWELL E]CATIONAND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO GOMPLY 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 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 DESCRIBED €SIDENi�IcLltluGTRT-tyl
PRO . BACKFILL SEPTIC TANKS❑
<-y = 4 SEEP.PIT(S)Ej CESSPOOLS Q
SIGNATURE j� jOF PERMITTEE... - Ltiyj�g....
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