HomeMy Public PortalAbout5027 PAL MAL AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
` DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF IAS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
CASSATT D. GRIFFIN, SUPT OF BUILDI143 ADDRESS -
FOR APPLICANT TO FILL IN LOCALITY ^_
BUILDING NEAREST
ADDRESS CROSS ST.
LOCALITY DISTRICT NO. SERIAL N0, PERMIT NO.
NEAREST
CRCSS ST. - ----— —
RECEIVED BY Ready for Inspection DA'rE ISSUED
OWNER I y
MAIL --- --- - USE ZONE I OCCUPANCY �~ BK MAP PC
ADDRESS
CITY TELAO.
CONTRACTOR CHARGES REIMBURSEMENT FEE
ADDRESS REQUIRED
--.--- IJOT REQUIRED
CITY TELAO. JOB NO CONNECTION t RGE FEE
-----�-- STATE ' CO.[MP. N0. a — —
REGISTRATION NO. COUNTY
LEGAL _ - - RECEIPT NO. i DATE 1 BY
LOT NO.
DESCRIPTION j
BLOCK TRACT _ WAIVER FOR RECORDING
OF BLDGS
. .
SIZE OF LOT NO — RECEIPT N0. ( DATE I BY
NOW ON LOT
USE OF
BUILDINGS TRUNK PERMIT NO.
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO ROAD PERMIT NO.
PUBLIC SEWER @ $ 3.50 -
HOUSE SEWER CONNECTING TO STATE ENCROACHMENT
PRIVATE DISPOSAL SYSTEM 1.00 I PERMIT NO. —
CONNECT ADDITIONAL BLDG.OR I INDUSTRIAL
WORK TO HOUSE SEWER 1.00 WASTE APPROVAL
ALTER OR REPAIR EXISTING
SEW ER OR DISPOSAL SYSTEM 1.00 I CONNECTION DATA
DISCONNECT AND ABANDON SEWER — —
AND/OR DISPOSAL SYSTEM 1.00 I STATION DEPTH
SEPTIC TANK,SEEPAGE PIT OR —
_PITS AND/OR DRAINFIELD 2.00 I MANHOLE REFERENCE 1
CESSPOOL—DRYWELL LOWER
SPECIAL CONDITIONS ONLY 2.00 I TYPE OF CONNECTION LENGTH FROM
Y. CURB "r:k. M.L.TO P.L.
OWNERS PERMIT $ I 1 00
AUTHORIZATION I TOTAL FEE
NAED
CONTRACTOIR TO CONNECT THE ABOVE D SCRIBEDDATE CONTRAED WITH THEIEXISTING 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
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL 0 DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR SEWER
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED NNECT AND
PLUG A
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDISCODON HOPLUG ND
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
WER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SEEP.PIT(S)17 CESSPOOLS U
SIGNATURE
OF PERMITTEE..---------------------- ......... =------•--. ---
,6A642D 663 12/52