HomeMy Public PortalAbout5760 RIO HONDO AVE_Sewer__ DEPAli.rMENT 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 r, NEAREST
ADDRESS CROSS ST.
LOCALITY 4 P DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST i- - A S
CROSS ST.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
– — -- — –
MAIL �
ADDRESS USE ZONE OCCUPANCY MAP
BK PG
CITY TEL.NO.
CONTRACTOR. C. Iloffingha,M rg T
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O' gmnlo Its-- CO.IMP.NO.
ADDRESS 59333 N. Cj()VEkj_y AL>! .
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CITY TE M PLE QL`.N'O.C:A L.I t.
---- TRUNK PERMIT NO.
r: STATE
REGISTRATION NO. G COUNTY ROAD PERMIT N0.
LEGAL
DESCRIPTION LOT NO. STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT INDUSTRIAL
SIZE OF LOT NO.OF BLDGS. WASTE APPROVAL
NOW ON LOT CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLICSEWER @ $ 3.50 RECEIPT NO. I DATE I BY
HOUSE SEWER GONNECTING TO i
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00 _
ALTER OR REPAIR EXISTING NO- I DATE 1 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 AMD/OR DRAINFIELD 2.00 STATION DEPTH
CESSPOOL—ORYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
- UPPER
TYPE OF CONNECTION LENGTH FROM
✓ CURB M.L.TO P.L.
OWNERS PERMIT $ 1 00 --
AUTHORIZATION TOTAL FEE .
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THE PUBLIC SEWER APPROVALS INSPECTOR'S SIGNATURE DATE
SIGNED THIS_.......___---DAY OF.___. .. _._... ........... 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT,,,-.,._.-------. BUILDING OR WORK
� � .� .,.--_..- SEPTIC TANK,SEEP.PITS)ADDRESS. .
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI• CESSPOOL[:] DRYWELL
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 C RTIFY THAT I ,.AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED S REQUIRE BY LO ANGELES COUNTY
AND STATE OF FORMA OR H -THE LEGAL OWNS ABANDON HOUSE SEWER
ER OF THE �, p1 SCRIB D E t P RT 4. BACKFILL SEPTIC TANKS Ej T
f' s SEEP.PIT(S)Ej CESSPOOLS 0
SIGNAZ' c ,,� '
OF PE1,04 7_E..
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