HomeMy Public PortalAbout9216 OLIVE ST_Sewer__ HDEPAUT'117iENT OF COUMM ENG». SEWER—SEWAGE DISPOSAL,
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
coum'H OF a.OS.ANGEMS BUILD ING
WILLIAM J. FOX, COUNTY ENGINEER I ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
ITT
BUILDS z1 � NEAREST .
ADDRESS �� ,(� i ,p CROSS ST. ,�` �✓4-- .�j✓ ���
LOCALITY ". C DISTRICT NO. SERIAL N0: PERMIT NO.
NEAREST _ AS
CROSS ST. jJ� RE/C�EIVED BY ri Ready for Inspection DAT�9ISSUED
�.
OWNER V.s 1-f r'� h �1 i o� s�� � —X! 6._) `i
MAIL
USE ZONE OCCUPANCY dlAa-
ADDRE38 �„`��� (,7 .�) /�. { ,� I BI( PG
CITYTEL.NO. A= 1 112
CONTRACTOR: rJ
40 "l642) OCIM,rt.x GfDT' co.IMP-NO. f _/
ADDRESS / / - .`. JOB NO. -
CITY TEL.N0. jo%L_ TRUNK PERMIT NO. - -"
REGISTRATION NO. /J q:2 '3�� COUNTY ROADPERMIT NO.
LEGAL rJ STATE..ENCROACHMENT -
DESCRIPTION LOT N0. ry :PERMIT NO.-- -
BLOCK :-TRACT " '' INDUSTRIAL r -
WASTE.APPROVAL,,
SIZE OF LOT / NO.OF BLOBS.
412 /5 NOW ON LOT CHARGE
USE-OF
DINGSbye ,o.
GE FF
NO. ' .DESCRIPTIO 13FFWORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO .�
•P.UBLICSEWER @ $ 8.50 RECEIPT NO.� DA E I BY'
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR. EXCEPTION RECORD
WORK TO HOUSE.SEWER 1.00
SUER OR REPAIR'EXISTINO NO. I DATE 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 ? �ye1 7 ,5—DEPTH
CESSPOOL—O RY W ELL "
SPECIAL.CONDITIONSONLY 2:00' f �,.���mANUHPOPE�iFERENCE.
TYPE06(Nt1ECT10N LENGTH FROM
OWNERS PERMIT $ ;1 00 UURR8 vE.R M.L.TO P.L.
AUTHORIZATION I TOTAL FEE I le� 15V
1 HAVE THIS DATE CONTRACTED WITH THE' HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'SSIONATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS--.tiL...._.....DAY OR_.EI�I-�- .....__._... 19. NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS. AGENT SEPTIC
-BUILDING R OR
' �• ..i---- SEPTIC TANK,SEEP.PIT(S)
ADDRESS.:._: .. _..�. ./_?l �i�_.L.S y.. ---.._-----�... AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI• CESSPO61L[] DRYINELL -"-
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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED UiRED: 'B GELES COUNTY ABANDON HOUSE SEWER
AND STATE OF IFORN OR 1 AM HE LEGAL OWN.
ER OF THE E D S IBE E L PROPERTY. BACKFILL SEPTIC TANKS
SEEP.PIT(S )[] CESSPOOLS d
SIGNATUR
OF PERMIT _..._._.
76"48A 602 7/53 /�