HomeMy Public PortalAbout5650 PERSIMMON AVE_Sewer__ il HDF.PARTM:ENT OF COUNTY EivG�M SEWER—SEWAGE DISPOSAL 1
DI`1ISION OF BUILDING AND SAFETY PERMIT APPLICATION
- COUNTY OF LOS ANGMES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
I_ADDRESS '(��5��"��s'S 9 M.Yvt[Si N►
FOR APPLIC NT_ `TO FILL IN LOCALITY--� c-- ,
BUILDING r NEAREST
ADDRESS.._.� � . �r�yg� f CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO.. PERMIT NO.
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NEAREST d+' / A
CROSS ST. r dP RECEIVED'BY Ready for Inspection DATE ISSUED
OWNER s - 1 / 'ZtN-4Gf r�t �." sir S3
MAIL
ADDRESS �p _ : USE 20 . OCCUPANCY MAP
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CITY TEL.NO. I I, ^'... .
CONTRACTOR ,� ��' - CO.IMP.NO.
ADDRESS JOB
TEL.NO. Cff TRUNK PERMIT NO.
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/ -"STATE ,
REGISTRATION NO. aa'3g COUNTY. ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT ,
DESCRIPTION LOT N0: PERMIT NO.
BLOCK TRACT 1 /V INDUSTRIAL
WASTE APPROVAL
NO.OF BLDGS.
SIZE F LOT c�f NOW ON LOT +G/ ' CHARGES
USE OF e '
BUILDINGS r / ��/ Glc" I- f-, Lr;�?..�' CONNE CHARGE FEE
NO. DESCRIPTION OF WORK FEE ` '
HOUSE SEWER CONNECTING TO REIMBURSEMENT
PUBLIC SEWER i 0.50 tJ T'y., RECEIPT NO: DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDO.OR EXCEPTION RECORDED
W09K'TO HOUSE SEWER .1.00 N0. I DATE I BY
ALTER OR REPAIR EXISTING .
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 DRAI:NFIELD 2.00 STATION , y DEPTH Gj
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 ) r 1 qpf �A AU REFERENCE
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9TYPE OF COVVNV.NECTIONN LENGTH FROM
OWNERS PERMIT $ I 00 L. M.L.TO P.L.
.AUTHORIZATION TOTAL FEE
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 SEWES
SIGNED.THIS__ DAY OF...�� _� ..14 NEW HOUSE SEWERNI
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OWNER. OR % - BUILDI00 G ORW IONAL
OWNERS AGENT:.. �f /_'.-;�?�.,.._..._.....____._ BUILDING OR WORK
ADDRESS....0 r
4.4. .L, 'E !Lo=?:fa a�.._.._... SEPTICTANK,SEEP..PIT(8)
AND/O,R DRAINFIELO
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI• CESSPOOL 0 DRYWELL o
CATION AND STATE THAT THE ABOVE 18'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/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 RE .DENT14%L PROPER BACKFILLSEPTICTANKS-05
_
SEEP.PIT(S)o CESSPOOLS
'SIGNATURE
DF PERMITTEE..._..✓r L==•e- ._ ;�/ i_ .�.... - - }
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