HomeMy Public PortalAbout5609 PERSIMMON AVE_Sewer__ DIEP RTALENT OF COUNTY YNG1NEER SEWER--SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FDX, COUNTY ENGg U i L D t N GINEER I ADDRESS
LOCALITY
FOR APPLICANT TO FILL IN
BUILDING NEAREST
ADDRESS CROSSST. I
LOCALITY DISTRICT NO, SERIAL NO. PERMIT NO.
NEAREST A ( 4�L s
CROSS ST. ----
ECE ED BY Ready for Inspection DATE ISSUED
OWNER
MAIL SE ZONE OCCUPANCY MAP
ADDRESS / BK PG
CITY TELAD.
CONTRACTOR ( i j.+� -=s>t- CO.IMP.N0. L ! 73-3
ADDRESS �ytGL)m�c JOB.NO.
CITY7_ ,f_ .Lby✓f- J TELAO. d�/ l/ .✓� TRUNK PERMIT NO.
STATE REGISTRATION NO. C� COUNTY
ROAD PERMIT N0, -
LEGAL TATE ENCROACHMENT
DESCRIPTION _LOT NO, FL44MIT NO,
BLOCK TRACT / IND RIAL
WASTE PROVAL
SIZE OF LOT N0.OF BLDGS. CHARGES
NOW ON LOT
USE OF
BUILDINGS CONNECTION CHA FEE
NO. DESCRIPTION OF WORK. FEE REIMBURSEMENT FEE
-� HOUSE SEWER CONNECTING TO —
p/ PUBLICSEWER @ $ 3.50 RECEIPT NO. TE iBY
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00 r
CONNECT ADDITIONAL BLDG.OR y EXCEPTION RECORD
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING DATE _
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 3
CESSPOOL—DRYWELL _
SPECIAL CONDITIONS ONLY 2.00 i ,, MAN-HOLE REFERENCE
ECTIj(UPPER, - -"
TYPE O� ON LENGTH FROM ,+�
Y. URB P.L. M.L.TO P.L.
OWNERS PERMIT $ 1 I 00
AUTHORIZATION TOTAL FEE I 4'e —
AED
CONTRACTOIR TO CONNECT THDATE CONTTE ABOVE DESCRIBEDWITH THEI EXIISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS....................DAY OF.._...._...............-......._......19___. NEW HOUSE SEWER T�
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT......... BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS.............................. AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL E] DRYWELL E]
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
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT ABANDON HOPLUG PLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS[]
SIGNATUREj4 �� L mai SEEP.PIT(S)E3 CESSPOOLS
OFPERMITTEE-_vvv -------- .-...... -............_..................... -