HomeMy Public PortalAbout4951 PERSIMMON AVE_Sewer__ DEP"_ MENT OF COUNTY ENGINEER SEWER--SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
ILDING
WILLIAM J. FOX, COUNTY EN13INEER � ADDRESS
FOR APPLICANT TO FILL. IN LOCALITYBUILDI
}_
ADDRENGr' ! - -- i-^ NEAREST
ADDRESS _ GROSS ST. __
LOCALITY J DISTRICT N0. SERIAL NO. PERMIT NO.
�.. A i 5
NEAREST _
CROSS ST. RECEIVED BY Ready for Inspection i DATE ISSUED
OWNED.
MAIL USEsGNE ! OCCUPANCY ASiT P
ADDRESS I RK PG
} 9
CITY TEt.i1ES. I '
CONTRACTCS �
CO -- GO.imp.140.
ADDRESS
—— ---- - -- - SOB N0.
CITY TEL.NO.
f, _ s TRUNK PERMIT NO.,
REGISTRATION NO COUNTY- ROAD PERMIT NO.
LEGAL
DESCRIPTION # i=:, STATE ENCROACHMENT
_ 1 DST NO:; _ PERMIT NO.
BLOCK TRACT INDUSTRIAL
y ;iL WASTE APPROVAL
SIZE OF LOT NO.OF BLDGS.
NOW ON LOT ✓ J CHARGES
USE OF
BUILDINGS y.%:y: - -- CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO _ REIMBURSEMENT FEE
PUBLIC SEWER @ $ 3.50 RECEIPT NO. ( DATE 4 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 N0. ( 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 DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHCL."3EFERENCE
_ TYPE OF CONNECT[O LENGTH FROM
I 00 Y. CURB M.L.TO P.L.
OWNERS PERIviIT ; P.L.j
AUTHORIZATION I TOTAL FEE 4`' ....
1 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 '
1NEW HOUSE SEWER
SIGNED THIS ........;.7 DAY OF__ ,t"�.�s,��,.,::..�_.. ,19��
OWNER OR
CONNECT ADDITIONAL
OWNERS 15 BUILDING OR WORK
4, s SEPTIC TANK,SEEP.PIT(S)
ADORES / l..."..:. rXJIIY {.... AND/OR DRAINFIELD
1 HEREBY ACKNOVHEDGE 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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND
DISCONNECT PLUG
AND/CR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUGAND
AND STATE OF CALIFORNIA OR THAT . AM THE LEGAL OWN-
E SEWER
ER OF THE ABOVE D.EaSCRIBED SIDENTIAt PROPS SACKFI L SEPTIC TANKS
OLS E]
SIGNATURE •i' �/ f��
OF PERMITT _.__,
e`
�76AG42A 663 7/531