HomeMy Public PortalAbout4926 PERSIMMON AVE_Sewer__ DEP"JUA ENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL3 4141
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDIRENG
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FOR APPLIFILL IN LOCALITY
BUILDING r �
ADDRESS � i. CROSS ST.
LocaLInr
1 DISTRICT NO. `SERIAL NO. PERMIT NO.
NEAREST 4 A
CROSS ST. c�RECEIVEDA Y Ready for Inspection DATE ISSUED
el OWNER
MAIL
ADDRESS USE40NE OCCUPANCY BK MAP PC
ti�`,„P'},���t r, I
CITY TEL.NO. + AUS
CONTRACTOR' • ' rnia e�`10 .or Const...-co, ch,-Lm P.N0:
ADDRESS ..C-al •groi90 -AV$"o JOB NO.
CITY PAL.Ate1.7ollo TEL.N'W'Ij n 3.x•5048
TRUNK PERMI 0.
REGISTRATION NQS�'}`- �i'� StER40,17NTY ROAD PERMIT N0. ✓`�
LEGAL '
DESCRIPTION LOT N0. STATE ENCROACHMENTPERMIT N0.
BLOCK TRACT INDUSTRIAL
NO.OF BLDGS. WASTE APPROVAL.
SIZE OF LOT ' � NOW ON LOT .,,*C H A R 0 E S
USE OF
BUILDINGS CONNECTION CH GE FEE
NO. DESCRIPTION OF WORK FEE REI MBU
HOUSE SEWER CONNECTING TO +gSEMENT FEE
PUBLIC SEWER 0 S X8:50 CEIPT NO. I DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO: i DATE I BY
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 :7* DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00t MANHOLE REFERENCE
LOWER
TYPE OF CONNECTION LENGTH FROM g
OWNERS PERMIT $ 1 00 Y. CURB L---pP.L. 'M.L.TO P.L.
AUTHORIZATION TOTAL FEE �Z7
I HAVE THIS DATE CONTRACTED WITH THE HERE N NAMED
CONTRACTOR TO. CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS IN$PECTO.R'SSIGNATURE DATE
DWELLING TO THE P BLIC SEWER //-
SIGNED THIS_�. DAY O (�' II. NEW HOUSE SEWERAlu
OWNER OR
CONNECT ADDITIONAL OWNERS AGENT BUILDING OR WORK
..:._.
ADDRESS........ ..... --------......_.r_...... SEPTIC TANK,SEEPwPIT(S)
- AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 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
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND
,LICENSED AS REQUIRED BY LOS AN COUNTY ABANDON HOUSE SEWER
AND.STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE D SC ED�RESIDENTIAL PROP RTY. BACKFILL SEPTIC TANKS O `
SEEP.PIT(S) CESSPOOLSE1 r BIG5• '�- +'
OF PERMITTEE � s --
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