HomeMy Public PortalAbout6623 OAK AVE_Sewer__ mEeART:aUENc OF 0=14W ExauaEEM SEWER—SEWAGE DISPOSAL
DIVISION OF BUMMING AND SAFE' PERMIT APPLICATION
COUNTY OF MIS "GELM
WILLIAM J. FOX, ccumTy Eamimcm BUILDING
( ADDRESS
P13 PPUCA T 1-4
LOCALITY
BUILDING NEAREST
ADDRESS 14 CROSS ST.
LOCALITY DISTRICT NO.�` Ready for Inspection PERMIT NO.
NEAREST s
CROSS ST. ---
� RE 1VED BY DATE ISSUED BY DATE
OWNER
MAIL ONO
SE ZONE OCCUPANCY MAP
ADDRESS � ' N CK PG
CITY TELNO.
CONTRACTO CO.IMP,NO.
ADDRESS !OB N0.
CITY T L.NO TRUNK PERMIT NO.
REGI TRATION 0. COUNTY
//ld 2�- -� ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO. y PERMIT NO.
BLACK TRACT INDUSTRIL
WASTE APPROVAL
SIZE OF LOT 8F SLOGS.
NOW ON LOT CHARGES
USE OF -
BUILDINGS CONNECTION CHARGE FEE
NO.1- DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER @ $ 3Z9RECEIPT NO. DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
i CONNECT ADDITIONAL BLDS.OR EXCEPTION RECORDED
_ WORK TO HOUSE SEWER
^�ALTER OR REPAIR EXISTING NO- DATE +BY
SEWER OR DISPOSAL SYSTEM 1.00 4
UPSCONNECT AND ABANDON SEWER
AND/QR DISPOSAL SYSTEM 1.00 CONNECTION DATA
'— SEPTIC TANK,SEEPAGE PIT OR
PITS AND,/OR DRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL – ---
SPECIAL CONDITIONS ONLY 200 MANHOLE REFERENCE
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT 1 00 _Y_ cLLuR_ -P.L: 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__...__.. _..___ __ y r..____ __ BUILDING OR WORK
ADDRESS............_.........---._--. SEPTIC TANK,SEEP'.PIT(S)
_._ .----•--_.._.__.. ..�. __.. AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL❑ ORYWELL 0
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
TERED
AgD/OR LICENSED EBY IFY THAT I AS REQUIRED BYPROPERLY
LOS ANGELES COUNTY
I188 DISCONNECT PLUG AND
ABANDON HOUSE SEWER
ER OF THE ABOVE DE IBED IDENTIAL PE BACKFILL SEPTIC TANKS
M
SIGNATURE
v `I SEEP.PiT(s)[] CESSPOOLS
..OF ERMITTEE • 1U�+++!Lti•'
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