HomeMy Public PortalAbout9573 PENTLAND ST_Sewer__ DEP".rMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES BUILDING C
WILLIAM J. FOX, COUNTY ENGINEER ADDRESS
-A ��/IA/'/
FOR APPLICANT TO FILL IN LOCALITY „d C
REI
ADSS _ GROSS ST.
LOCALITY DISTRICT NO. a� SERIAL NO. PERMIT NO.
NEAREST A 3
CROSS ST.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL
ADDRESS — USE ZONE CCCUPANCY I fAAP
-- I Qi< PG
CITY TEL,NO.
CONTRACTOR_ i CO.IMP.NO.
ADDRESS 10B N0.
/ .
CITY TEL.NO• TRUNK PERMIT NO.
STATE
REGISTRATION NO. H COUNTY ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. PERMIT NO.
BLOCK TRACT C( ' ) E,. INDUSTRIAL
WASTE APPROVAL
SIZE OF LOTN0.OF BLDGS.
t.,l', . NOW ON LOT t CHARGES 'y
USE OF -,
BUILDINGS CONNECTIO-N.CtHARGE FEE
NO DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
I HOUSE SEWER CONNECTING TO �--
PUBLICSEWER @ $_3.50 RECEIPT NO. IJ SATE BY
HOUSE SEWER CONNECTING TO f /
_ PRIVATE DISPOSAL SYSTEM 1.00 -
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
_ WORK TO HOUSE SEWER 1.00_
ALTER OR REPAIR EXISTING NO. I DATE BY
_SEXVER 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
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
— _Upp-za_. LOWER
—�—._ TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT ; I 00
Y. CURB P.L. M.L.TO P.L.
AUTHORIZATION ( TOTAL FEE
I
HAVE THIS DATE CONTRACTED W1TH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
i
SIGNED THIS_---------_------.DAY OF..... _...............................14.._... NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT.-.._ BUILDING OR WORK
...
ADDRESS._...........__.._.-..-._._- SEPTIC TANK,SEEP.PIT(S)
---.._.--. ---.__-_----._.--_......................_... AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI• CESSPOOL❑ DRYWELL❑ �—
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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN.
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS I
SEEP.PIT(S)GI CESSPOOLS❑ I
SIGNATURE
OF PERMITTEE............--•--------------.....................
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