HomeMy Public PortalAbout10613 ROSEGLEN ST_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
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 ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST w A S
CROSS ST.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL
ADDRESS USE ZONE OCCUPANCY MAP
BK PG
CITY TEL.NO.
CONTRACTOR
CO-Imps NO.
ADDRESS
JOB NO.
CITY TELAO.
TRUNK PERMIT NO.
STATE
REGISTRATION NO. COUNTY ROAD PERMIT N0.
LEGAL
DESCRIPTION LOT NO. < STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT F/ 'C, INDUSTRIAL
SIZE OF LOT N0.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
PUBLIC SEWER @ $ 3.50 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- I 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 Luwsm
TYPE OF CONNECTION LENGTH FROM
OWNERS I PERMIT $ 1 00 Y. CURB P.L. M.L.TO P.L.
AUTHORIZATION TOTAL FEE ,! 1.
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.PIT(S)
-- - - — - - AND/ORDRAINFIELD
I HEREBY ACKNOWLEDGE THAT I 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.
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED SEWAGE DISPOSAL SYSTEM
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE SEEP.PIT(S)[:] CESSPOOLS❑
OF PERMITTEE---
76A642D 663 1/53
1.