HomeMy Public PortalAbout5814 PRIMROSE AVE_Sewer__ i'YEPARTMENT OF COUNTY ENGLNFFR SEWER--SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY EN13INEER I BUILDING / )
ADDRESS s A 7 —�
FOR APPLICANT TO FILL IN LOCALITY
BUILDING ' 7 NEAREST
ADDRESS _ i !`f✓- f // , L+SCP CROSS ST. (�
LOCALITY r�� �' j DISTRICT NO. SERIAL NO. PERMIT NO. C
NEAREST ) A
CROSS ST CEIVED BY Ready for Inspection DATE ISSUED
E
OWNER � IVA7MIL
MAIL / ' , , USE ZONE OCCUPANCY MAP
ADDRESS J 7 /� /3� s - P /:'d ti' BK PO
CITY` '7 j/y ,-` �"�,� TEL.NO.
CONTRACTOR ?
CO.IMP.NO. 1
ADDRESS
JOB.N0. --
CITY TEL.NO11 o�'6"__j,7/7 TRUNK PERMIT NO.
STATE
REGISTRATION NO. /S_y�L-: COUNTY ROAD PERMIT NO.LEGAL
DESCRIPTION LOT NO. STATE ENCROACHMENT _
ff✓ / _PERMIT NO. _
BLOCK TRACT ,f `" • j INDUSTRIAL .._r
WASTE APPROVAL
SIZE OF LOTN
0.OF BLDGS.
NOW ON LOT f CHARGES
USE
BUILDINGS ' ��/� CONNECTION CHARGE FEE
�i� �L l/' �„
NO. DESCRIPTION OF'VWORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER_ @ $ 3.50 I RECEIPT NO. DATE 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 DEPTH
CESSPOOL—DRYW ELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTIONLENGTH FROM
Y. CURB P.L. M.L.TO P.L.
OWNERS PERMIT s I 1 00
AUTHORIZATION I TOTAL FEE
IHAVE CONTRACTORS DATE TO CONNECT THTED WITH THE E ABOVE DESCRIBED EXISTING AED PPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS..._......__.....DAY OF..._. .._._.--......_.__. NEW HOUSE SEWER 'r. , .
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT..........._. _ BUILDING QR WORK
SEPTIC TANK,SEEP.PITS)
ADDRESS—..............----------._............_........__.__._._...._.........._.._......_... AND/OR DRAINFIELD
1 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
DISCONNECT PLUG
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE f SEEP.PIT(S)[] CESSPOOLS[]
_
OF PER
MITTEE_-..
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