HomeMy Public PortalAbout10618 ROSEGLEN ST_Sewer__ DEPAKTMENT 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 T.9 FILL INLOCALITY
BUILDING Of, NEAREST
ADDRESS " -CROSS ST. - -�—=
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEARESTA S
CROSS ST.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL /
ADDRESS 1 USEZONE I OCCUPANCY MAP
BK PG
CITY TEL.NO.
CONTRACTOR CO.IMP.NO.
I
ADDRESS
JOB NO.
CITY TEL.NO..0&J, 44-lllel' TRUNK PERMIT NO.
(4,1 H STATE
REGISTRATION NO. ROAD PERMIT N0.
LEGAL
DESCRIPTION LOT N0. STATE ENCROACHMENT
LJ�y PERMIT NO.
BLOCK TRACT `J/ INDUSTRIAL
II WASTE APPROVAL
SIZE OF LOT N0.OF BL /�
NOW ON LOT j[ CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE 104-
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER Cal $ 3.50 RECEIPT NO. I DATE I BY
HOUSE SEWER CONNECTING TO
PRSVATEDISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO- DATE I 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/OR DRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
_SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
Y
OWNERS PERMIT : I 00 Cu" P.L. M.L.TO P.L.
AUTHORIZATION TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
HAVE
TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS--------------------DAY OF........................................19...---- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT--...----------..------------•-------------------------------------------- BUILDING O R WORK
SEPTIC TANK,SEEP.PITS)
ADDRESS----------•--------------...---...---------------------------------------------------- AND/ORDRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI• CESSPOOL❑ DRYWELL❑
CATNON 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 CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HO USES EWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE � %q,/^'/)/- .� SEEP.PIT(S)E] CESSPOOLS
OF PERMITTE '.V.... -J..�
76A642D 663 1/53 -