HomeMy Public PortalAbout5560 PAL MAL AVE_Sewer__ DEP/ARTMHRT OF COUNTY "GWEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS AINGFJ W
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING
ADDRESS O
DU ILDINGFOR APPLICANT TO FILL IN NEAREST
LOCALITYADDRESS rS l0(/ i� �--J2 s CROSS 8T.
LOCALITY `��
DISTRICT NO. SERIAL NO. PEMIT NO.
NEAREST F) A /'1N/_---/� � � �?/ S
GROSS
ST.
y/ PEC IV ED Y Ready or h 0a tion DATE ISSUED
OWNERAIL
ADOREBS 'S S g9e Y7 .CJQ/' /�� - USE ZONE Q�OCCUPANCY ! BE MAP pe T
TELMD.
CONTRACTOR /
CO.INP.N0.
ADDRESS JOB.MO.
Cin TELMD. TRUNK PERMIT NO.
STATE
REGISTRATION NO. COUNTY ROAD PERMIT NO.
LEGAL ' 0 STATE ENCROACHMENT
DESCRIPTION LOT NO. PERMIT NO.
BLOCK TRACT'a, �!'LiI�C® .f INDUSTRIAL
WASTEINDUSTRIAL
SIZE
OF LOT - NO.OF BLDGS. �/
JJ 2 X.?D 0 NOW ON LOT CHARGES
USEOF
BUILDINGS
DI — CONNECTION CHARGE FEE
BUILDINGS f-�G-+tr`
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTINS TO
PUBLIC SEWER M = 3.50 RECEIPT N0. I DATE I BY i
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLOC,OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO. I DATE BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/ R DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR GRAINFIELD 2.00 STATION DEPTH
CESSPOOL—ORYWELL
$SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCEUPPERLOWER
TYPE OF CONNECTION LENGTH FROM
Y. CURB P.L. M.L.TO P.L.
OWNERS PERMIT S I OD
AUTHORIZATION TOTAL FEE = �J
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
SIGNED THIS-----_..-__.DAY OF_._._____-__—_19__ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
ORWORK
OWNERS AGENT—_...___._____.._.._.._.___.._..___---._..___..__._ JC
SEPTIC TANK,SEEP.PIT(S)
ADDRESS........... AND/ORDRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOLQ DRYWELLE]
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
AND/ORDISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDONHOUSE S AND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILLSEPTICTANKS Ll
j/�L�/ ,g y SEEP.PIT(8)D CESSPOOLS
SIGNATURE <Y '�riT�_`�"{u.^�'�(
OF PE RMITT EE..i�._:
76AG42A 663 7/53 �(