HomeMy Public PortalAbout5632 PERSIMMON AVE_Sewer__ EF•-66663 i2.54
S$ APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER--SEWAGE DISPOSAL
Department of County Engineer
County of Ice Angeles as � ISN
WM.J. FOX., COUNTY ENGINEER
CASSATT D.GRIFFIN, SUP'v Or BUILDING L.QGAL'TY
FOR APPLICANT TO FILL IN NEAREST
DESCRIPTION �LOT N0 OWNER
BLOC. TRACT3" MAIL 5--
�' -- - _._..
ADDRESS V/� .�
NO. OF BLDGS. -
S17E OF LOT NOW ON LOT
CITY _ TEL.NO.
USE OF
SUILDiNGS P _ -
_�_ DISTRICT NO. GROUP MAP
�- RIC
CONTRACTOR BK PG _
ADDRESSl - -
�' f`�r'". � •; ;',i✓-� �;" C®I1I+IEf".TY0N DATA
TEL.NO �' '' _ STATION - - DEPTH
STATE MANHOLE REFEREF
REGISIRATIO N0. d X -r, [I COUNTY _ UPFEft LOWER
TYPE OF CONNE".IOC! LENGTH FROM
DFSCRIPT[ONSOF WORK FEE _Y• CURB ' - P.L. M.L.TO P.L. -
H0 SE SEWER CONNECTING TO
PUBLIC SEWER (:ii� 3.50
_ ! .
I HUJS'E ScVJER
CONNECTING TO -
PRIVATE_DISPOSAL SYST_Eiw_ 1.00_{
' CONNECT ADDITIONAL BLDG, OR CO. IMP.NO. JOB. NO.
WORK TO HOUSE SEWER 1.00
—�--A LI`EROR REPAIR EXISTING - I i�-_� -
_ SE,JJER OR DISPOSAL SYSTEM I-QO i iR!,1NK PERMITNO, ROAD PERMIT NO
D CON'NE T AND ABANDON SEWER _._..-
_
ANJ!-O-R--C-i-J-P05nL SYSTEM PERMIT_NO.STATE ENCR
OACHNENI
SEPT!C TANK,SEEPAGE PIT OR
P 1a AI4D OR D'RAINFIE_LD 2 00 I INDUSTRIAL -
fK�jP00' WASTE APPROVAL
>' L CL3�l D17101d5 ONLY 2 00_�
CIAf
._._ _. CHARGES
CONNECT!ON CHARGE FEE
Ovam's PERMIT s t , Oq
AUTHORIZATIONTOTAL FEE REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN -NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TO CONNECT THE ABOVE DESCRIBED EX.STING DWELLING
TO THE PUBLIC SEW! i,.- ,1
SIGNED THIS AY OF 191- NEW HOUSE SEWEROWNER OR
a
r w CONNECT OR
IRK
AL
OWNERS ACtNT 'r' .� ;' %. v .tG BUILDING OR WORK
s. --
`' af, _ SEPTIC TANK SEEP, PITS)
ADDRESS AND/OR DRAIN_ :LD
HEREBY ACKNOWLEDGE THAT I I.AVE READ THIS APPLICATION CESSPOOL[! DRYWELL
AND 5TATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE. LAWS REGULATING ALTER, REPAIR,SEWER OR -
PLUMBING AND SEWERS, SEWAGE DISPOSAL SYSTEM
I HER€BY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR '----��- -�
LICENSED AS REOU!RED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL 0 NER THE ABOV _ABANDON HOUSE SEWER
ESCR!BEESt Dt;Al IAL PFOP;;Rif
BACKFILL SEPTIC TANKS[]
X+v SEEP.PIT(S)
iGNATU. B.
OF PERMITTEE -
WILLIAM J. FOX, COUNTY ENGINEER VAI.II ATION
BY 1 BY, _ p
DEPUTE DEPUTY
BY BY
0 DEPUTY DEPUTY