HomeMy Public PortalAbout5621 PAL MAL AVE_Sewer__ D$FAsINER1T OF 40OUNTY EXCUNRM SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUIIMING AND SAF= PERMIT APPLICATION
OOIINTY OF LOB ANOffi.F8 BI1JIILDINB
WILLIAM J. FOX. COUNTY ENDIN[[N I ADDRESS S� Z ' r• RL ///.CLL
F
UCANT TO LL IN LCROSSST
P&E C� r1BUILDIAREST
I Al V OAKT NO ReAftforineOeeUou PERMITNOC�v 1+7 JD'BT DAT[ SS ED Y DATERry/')9 �k OCCUPANCY e BK YAP PS
ADDRESS _
CITY E0 'P TELNO O 7615 yJ
CONTRACTOR w h r r CO.Imp NO
ADDRESS e
}� \B NO
CITY �j..... roz� EL NO //D� _2761S TRUNI`PERNIT NO
STATE
REGISTRATION NO COUNTY ROAD PER T NO
LEGAL . I✓EG K 57ATE ENCflO XMENT
DESCRIPTION LOT NO 7'N, IP Sp%,, STATE GIC PERMIT NO
BLOCK TRACT T O Z Z INDUSTRIAL
r� WASTE APPROVAL
SIZE OF LOT kOX41 F 1 NOW ON LOTS� ?� HARSEES
E OF
BUILDINCe I DIP N C DT/ R jtf0P,
C CONNECTION CHARD!FE
NO. DESCRIFTION OF WORK FEE REIMBURSEMENTF
/
HOUSE SEWER CONNECTING TO
PUBLICSEWER ! i 888 _�' V RECE17I DAT[ BY
OU—OUCONNECTING TO
PRIVATE DISPOSAL SYSTEM 100 _
CONNECTADDITIONAL 8LD0 OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 100 00
WLfIFff RSB EXISTING N DATE BY
SEWER OR DISPOSAL SYSTEM 100
0ISCONN�AND ABANDON SEWER
AMD/OR DISPOSAL SYSTEM foe CONNECTION DATA
SEPTIC TANK SEEPAGE PIT OR
PITS AMD OR DRAIMFIELD t00rSTATION
DEPTN
RYWE L y79iSPECIAL CONDITIONS ONLY 200 MANN RENCE
RB ECTIONYELTO PLRCMOWNERS PERMIT ; 00AUTHORIZATION TOTAL FEEI NAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINGALS INBP[CTOWS SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS DAY OF it NEW HODS[SEWER
SER OR CONNECT ADDITIONAL
WNWNERS AGENT SUILDINS OR WORK
ADDRESS_ SEPTIC TANK.SEEP.1 ITIS)
AND OR DRAINFI[LD
I HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLI• CESSPOOL❑ DRYWELL❑
CATION AND STATE THAT THg ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER.REPAIR SEWER OR
REGULATING PLUMBIN ANO SEWERS. SEWA E DISP01<AL SYSTEM
A ID/OR LICENSED IFY THAT I AS REQUIRED BY PROPERLY
ANGELESSICOUNTY
I0 DISCONNECT PLUG AND
AMD STATE Of CALIFORNIA OR THA 1 AN THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBE R IAL PROPERTY PTIO TANKSII'T�
. SEEP PIT(S)❑ CE88POOLS ,�•
SIGNATURE
OF PERMITTEE
TBA602D SAN ett 4/04 G