HomeMy Public PortalAbout9128 PRIMROSE AVE_Sewer__ DEPARTNUENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
+ nT.,�;�N OF BUILDING AND SAFETY � PERMIT APPLICATION
COUNTY OF'LOS ANGELES
'WILLIAM J. FOX, COUNTY ENGINEER BUILDING-
ADDRESS
FORy APPLI �yN�T TO FIL IN LOCALITY
ADDRESS �.[; ftP � + .Al-lea,L KA). NEAREST
CROSS ST.
DISTRICT NO. SERIAL NO. PERMIT NO.
LOCALITY•®�ddry ,� _ . .� � _
CROSS ST. �63 l�y Lam/ ,6 A 3 �° �V lei 45-3 S
RECEI ED BY Ready for fispectleal DATE ISSUED
OWNER
MAIL
DDRESS ra G. ,� USE20NE OCCUPANCY BK MAP PG t
A / ��-, g
CITY
it ��' Ga L.NO. I t
I
CONTRACTOR -/ .�dj //��� CO.IMP.N0. �+
ADDRESS
g: f d� JOB N0. ��
CITY figlploil-*TEL.NO. 0 2 / J TRUNK PERMIT NO.
�.:_ = STATE
REGISTRATION N0. , w t COUNTY- ROAD PERMIT N0. ~� u�
LEGAL STATE ENCROACHNER I
DESCRIPTION LOT N0. '
PERMIT NO.
BLOCK TRACT INDUSTRIAL
Qj/ WASTE APPROVAL
SIVE OF LOT /Eq �NOW ON LOTS CHARGES
USEOF
BUILDINGS i�r��� I® CONNECTION CHARGE FEE
NO. DES RIPTION-OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO -
PUBLIC8EWER 5 5.50 T- RECEIPT NO. I DATE I BY
HOUSE.SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00 Qo:
ALTER OR REPAIR EXISTING NO• I DATE I BY
SEWER OR.DISPOSAL SYSTEM I: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—ORYWELL
SPECIAL CONDITIONS ONLY. 2.00 .ANHOLE REFERENCE, j�1
- UEPEB� t "v"y LOWER
TYPE OF CO NECTION LENGTH FROI
OWNERS PERMIT ; k 00 --- CURB M.L.TO P.L.
AUTHORIZATION TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO TrrH�E PUBLIC SEWER
SIGNED THIS.. �4 ...DAY OF_. _. .._r.._14 NEW HOUSE SEWER ��J�.,���" -053
OWNER OR �S CONNECT ADDITIONAL t'
OWNERS AGE T_- ..,SA. j' BUILDINGORWORK
S 1 :SEPTIC TANK,SEEP.PIT(S)
ADDRESS....._. ..... Ktd�-a.,=' '�e.. �__._-........:� •AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT. 1 HAVE READ THIS APPLI- CESSPOOL[] ORYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAW*, ALTER.REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 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 CA
LI RNIA OR THAT I AM E L GALJOWN-
ER OF THE ABOVE - CRIB R IEDEP P FY BACKFILL SEPTIC TANKSEl
SIGNATURE 7. � SEEP.PIT(S)O CESSPOOLS --A C- .l ,F,-J�;�'• ,r''' �i
OF PERMITTEE..._. _......:__._�..:..b� ._...._
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