HomeMy Public PortalAbout5571 ROBINHOOD AVE_Sewer__ DEXAIrmENT OF OOUNTY ENGINIUM o $ kEWER—SEWAGE DISPOSAL 1
DIVISION OF BUH-DING AND SAFETY PERMIT APPLICATION
OOUNTY OF LOS ANQEY /
WILLIAM J. FpX. COUNTY lZNOINQR ADDRESS/
FOR APPLICANTJO FyL IN LOCALITY
BUILDING NEAR
ADDRESS Al CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST
Jr10 15a :3x S
CR068 ST.
REC VED B Reaft fsr IssfwtleIl DAi ISAYED
OWNER J :
AD D MRESBAIL s L E f0 OCOUPAMOY
SK 9
CITY
CONTRACTOR
ADDRfiSS
JOB.M0.
CITY TELMO. TRUNK PERMIT NO.
STATE
REGISTRATION NO. ROAD PERMIT M0.
LEGAL
DESCRIPTION LOT N0. l� STATE ENCROACHMENT
lrp PERMIT NO.
BLOCK TRACT / 7 INDUSTRIAL —
WASTE APPROVAL
SIZE OF LOT 7OX O D M0.OF BLDGS C}tARGE
NOW ON LOT
USE OF
BUILDINGS r CONNECTION CHAR E
NO. DESCRIPTION OF WORK FE[
REIMBURSEMENT FEE
HOUSE 8EWfiB da IM 0
PUBLIC SEWER 411 111 L54 RECEIPT M0. BY
HOUSE E M IMG TO
PRIVATE DISPOSAL SYSTEM Im
CONNECT ADDITIONAL 13LDCL OR EXCEPTION REOORDE
WORK TO HOUSE SEWER 1.00
ALTER G NO' DATE B
IL SEWER LSYSTEM 10�
DISCONNECT AND ABANDON SEWE■
AND/OR DISPOSAL SYSTEM 1.09 CONNECTION DATA
8 AN
PTAND/OR,SE PA PIT OB
PITS AMD OR DRAINFIELD !.M STATION S, j D
CESSPOOL--0RYWELL
SPECIAL CONDITIONS ONLY 2-M - MANHOLE REFERENCE
R
TYP `CENOTH FROM
OWNERS PaMrr s I 00 L
AUTHORIZATION TOTAL FEEI HAVE DATE �.
MED
OONTRAOTOIR TO CO NECT�TH�E A ED 0 E DESCRIBEDWlTH THE HEREIN
APPROVALS SPE R'SSIGNA R
DWELLING TO THE PUBUD SEWER
SIGNED THIS DAY OF Iq NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWME88 ADEM ! . BUILDING OR WORK
i SEPTIO TANK[SEEP.PIT(S)
ADDRESS '' �' AND/OR DRA NFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS API-Ll- CESSPOOL❑ DRYWELL❑
CATIONAMD STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STAT[ LAWS ALTER.REPAIR IlASEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOL SYSTEM
I HEREBY CERTIFY THAT I AY PROPERLY REGISTERED
AMD/OR LICENSED AS REQUIRED BY LOS ANGELES OOUIITY DISCONNECT PLUG AND
AMD STATE OF CALIFORNIA OR THAT I AN THE LEGAL OWN- ABANDON HOU8ESEWER
ER OF THE ABOVE DESCRIBED REWDEY PROPERTY. BA !-P'TIO TANKS❑
SIGNATURE SEEP.PIT(S)F] CESSPOOLS E]
OF PERMITTEE
TOAS42A SLS T/01