HomeMy Public PortalAbout5116 PAL MAL AVE_Sewer__ m�Axa � OF COUNTY EPTG}IIS SEWER—SEWAGE DISPOSAL
DIVISION OF BUELDING AD SMETY PERMIT APPLICATION
COUNTY OF 5.09 ANGELM BUILDING
WILLIAM J. FOXr COUNTY ENOIN62R (_ADDRESS , # A PA,/ A,4/
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FOR)AP//PLICANT O FILL IN LOCALITY r1C1jAA - C/.ry
ADDRESS /�l()_ CROSS ST. 0 140,(q 0 do
LOCALITY 1 Z �.
DISTRICT NO. Ready for InsPestlon PERMIT NO. c
NEAREST .� `�
CROSS ST. /
-7 V
RECEIVED ELYDATE ISSUED BY DATE
OWNER
MAIL U ZO E OCCUPANCY BK MAP PO
ADDRESS
CITY TEL.NO. y r®�u �® X/W��� 4 171?
CONTRACTOR r ;
CO.IMP.N0.
AODRE
JOB NO.
CITY �/ TE .N
TRUNK PERMIT NO.
REGISTRATION N0, pJ 1 ® COUNTY
ROAD PERMIT N0.
LEGAL / a ISTATE ENCROACHMENT
DESCRIPTION LOT N0. PER IT NO.
r
BLOCK TRACTJ` , ® j .WASTE WAS
�� / OW ON LOT
,NS
SIZE OF LOT S //�� T,� �_ CHARGES
USE
t'CONNECTION CHARG E
NO. DESCRIPTION OF WORK,/ FEE REIMBURSEMENT FE
HOUSE SEWER CONNECTING TO
PUBLICSEWER a $ 3.60 RECEIPT 1110,0' D I BY
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORD
WORK TO HOUSE SEWER 1.00
ALTER OR.REPAIR EXISTING ti NO- I DATE
SEWER OR DISPOSAL SYSTEM 1.00
DISC_ D%OR D SPOSAL SYSTEMN SEWER
NNECT AND ABANDO
AN1,00
CONNECTION DATA
SEPTIC-TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION �',�� DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS'ONLY 2.00 g MANHOLE REFERENCE
UPPER LAR
TYPE OF CONNECTION LENGTH FROM �r
OWNERS PERMIT E I O0 W'' CURB .�: M.L.TO P.L. .9
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR T0. CONNECT THE ABO E DESCRIBED EXISTINGAPPROVALS INSPECTOWSSIGNATURE DATE
DWELLING TO THAPURLIC SEWER
SIGNED THIS DAY OF 19 'NEW HOUSE SEWER
OWNER 0R CONNECT ADDITIONAL
OWNERS AGENT _ BUILDING OR WORK
/, J _ 91, SEPTIC.TANK,SEEP.PIT(S)
ADDRESS...4� /_L ._ 'f'�`" ;. ND/OR TANK,
BEEP.
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS A P 1- E7SSPOOL[] DRYWELL
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
AND%OR LICE SED IFY AS REQUIRED By
YAM PLOS AN ELES COUNTY
N DISCONNECT PLUG AND
A D STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RE8ID •1'AC PROPER BACKFILL SEPTIC TANKS
SIGNATURE SEEP:PIT(8)� CESSPOOLS
OF PERMITTEE_SSS___......� �,.e�� 4 !YV//'`hf W �
70A642D SBcE 663 4/64 ise