HomeMy Public PortalAbout5238 PAL MAL AVE_Sewer__ OEPARTIN NT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
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 t
ADDRESS ' CROSS ST.
LOCALITY
DISTRICT 140. SERIAL NO. PERMIT NO.
e,� �
NEARESTr—.v v A
CROSS ST. O^f. $ F".� -----
-� PICEIVED BY Ready for Inspec ic" DATE ISSUED
OWNER rlMAI �
ADDRESS USE ZONES OCCUPANCY BK MAP PG
CITY , TEL N0.=.�� .' �'7 1—i::,
x
CONTRACTOR f CO.IMP.NO.
ADDRESS JOB.NO. _.
s.
CITY TEL.NO. r TRUNK PERMIT NO.
STATE
REGISTRATION N0. COUNTY _
ROAD PERMIT NO.
LEGALSTATE ENCROACHMENT
DESCRIPTION LOT NO. J PERMIT NO.
BLOCK TRACT 'I ' :'. ! INDUST APPROVAL
SIZE OF LOT �j� , Z5 I NO BL NOW ON LOTS
CHARGES
USE OF
BUILDINGS o+ CONNECTION ARGE FEE
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO ----
PUBLICSEWER @ $ 3.50 _ RECEIPT NO. DA j BY
HOUSE SEWER CONNECTING TO f
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED i
WORK TO HOUSE SEWER 1.00 N0. DATE BY
ALTER OR REPAIR EXISTING
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
DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 ° MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION: LENGTH FROM
OWNERS PERMIT ; I I 00 " P L. M.L.To P.L.
AUTHORIZATION I TOTAL FEE
I 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 es,
SIGNED THIS......,, f
.........DAY OF... ...I4.,.__ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT__..................._......_................. BUILDING BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS_ ..c:............._i.•------'-`--'– `` '•.............._.._------_.............. AND/OR GRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP,PLI- CESSPOOL I] DRYWELL E]CATIONAND 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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED PLUG
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND
DISCONNECT ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS E]
SIGNATURE
SEEP.PIT(S)E] CESSPOOLS 0 .5a..I y> e
�� ..� '
OF PERMITTEE... ... 1.– . `^ -----•- --- = -----•-----
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