HomeMy Public PortalAbout10601 ROSEGLEN ST_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 APPLICANn TO FIL I LOCALITY
BUILDING NEAREST
ADDRESS �� (Ar Q� CIZ� CROSSST.
LOCALITY r DISTRICT NO. SERIAL NO. PERMIT N0,
NEAREST
CROSS ST. S
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL USE ZONE OCCUPANCY MAP
ADDRESS I BK PG
CITY TEL.NO. ;: 4
CONTRACTOR
ADDRESS
JOB NO.
CITY TEL.NO.
TRUNK PERMIT NO.
– ❑ STATE
REGISTRATION NO. ❑ COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF BLDGS.
NOW ON LOT 1 CHARGES
USE OF
BUILDINGS .. CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER @ ; 3.50 g 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
ALTER OR REPAIR EXISTING NO- DATE 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/ORDRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
_SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT ; I 00
Y.– CU"m P.L. M.L.TO P.L.
AUTHORIZATION I 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
ADDRESS----------------------------------------------•--••--------------••------•–...--...
- SEPTIC TANK,SEEP.AND/OR DRAINFIELD IT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI. CESSPOOL 0 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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT ABANDON HOPLUG PLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE SEEP.PIT(S)E] CESSPOOLS
OFPERMITTEE....--J--•-• -----–------' = ----•-------` – – ..–......–
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