HomeMy Public PortalAbout10619 ROSEGLEN ST_Sewer__ DEPAWrMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OE 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 A S
CROSS ST.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER ��. ✓; !
MAIL 'I`J !a - OCCUPANCY MAP
ADDRESS •—mss . USEZONE I I BK PG
CITY TEL.NO.
CONTRACTOR. "
CO.+MP:-N0.
ADDRESS �. V(J , yt ..{ 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 a`'/ INDUSTRIAL
f WASTE APPROVAL
NOW O
SIZE OF LOT NO.i ON LBLOT
/'
OT CHARGES
USE OF
BUILDINGS '" ,• A ° �%r ri s CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER s 3.50 RECEIPT NO. 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 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/ORDRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE ,
Ui!RER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ 1 00 Y. C"B, P.L. M.L.TO P.L.
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS--------------------DAY OF............ 19-..---•• NEW HOUSE SEWER a
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT--------------------------------------------------------------------- __ BUILDING O R WOR K
ADDRESS------------------_-----------------------------............-......................-
... SEPTIC TANKSEEP.AND/OR DRAINF ELD PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI• CESSPOOL Ej 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 1 AM PROPERLY REGISTERED R DISCONNECT PLUG AND
AND/OLICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUGAND
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)Ej CESSPOOLS E]
)t
OF PERMITTEE--,------ --- w -
76A642D 663 1/53 �t. V4;�" .i - t f.
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