HomeMy Public PortalAbout5957 PRIMROSE AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING NEAREST
ADDRESS CROSS SL
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST A .-__ ._ - S
CROSS ST.
RECEIVED BY Ready for Inspection BATE ISSUED
OWNER
MAIL
ADDRESS - USE ZONE OCCUPANCY MAP
----- � BK PG
CITY — TEL.NO.
CONTRACTOR
CO.IMP.NO.
ADDRESS
_._._ JOB.N0.
CITY TEL.NO. TRUNK PERMIT NO,
STATE
REGISTRATION N0. �°' a`�yl COUNTY ROAD PERMIT NO.
LEGAL '
DESCRISTATE ENCROACHMENT
PTION'- Ltf�N PERMIT NO.
BLOCK TRACT INDUSTRIAL
------- WASTE APPROVAL
SIZE OF LOT ' ._ N0.OF BLDGS.
NOW ON LOT CHARGES
— -`_!--`- '9
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. I DESCRIPTION OF `OPIC FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER 0 $ 3.50 RECEIPT NO. DATEI 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` DATE BY
SEWER OR DISPOSAL SYSTEM 1.00
6-mm- CT NNEAND ABANDON SEWER
AND/OR DISPOSAL SYSTEM IAO CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 I MANHOLE REFERENCE
UFFER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS ; I I 00
Y. CURBP.L. M.L.TO P.L.
PERMIT
AUTHORIZATION TOTAL FEE 1 -
I 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
SIGNED THIS.-------...........DAY OF.. 19_e NEW HOUSE SEWER
OWNER OR
CONNECT ADDITIONAL OWNERS Af,ENT'._-.-:.._- -----............ ...,-•--..,-_..................................-
BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS...... i..._-._._________.-..____................._......_._...._..__- AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL❑ 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 DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SEEP.PIT(S) CESSPOOLS
SIGNATURE'
OF PERMITTEE.. ------------ ---
76A642I) 663 1/53 " ,