HomeMy Public PortalAbout10627 ROSEGLEN ST_Sewer__ DEPAIMEENT OF OOUNi'Y IENQU41CM SEWER-SEWAGE DISPOSAL 1
DIVISION OF BIIII.DING AND SAFETY PERMIT APPLICATION
OOUWW OF LOS eNG1111 B
WILLIAM J. FO)(- CouNTY EmcomErR BUILDING /
ADDRESS 16 6 7 -L i.+e J r_ - L'¢-L,,
FOR APPLICANT T FILL IN UMALITY
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ADDRESS CROSS ST
LOCALITY DISTRICT No. SERIAL NO. PERMIT NO.
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SIZE OF DT N0.OF Q Ql
NOW ON DT OHARGES
USE OF
BUILDINGS OONNEOTION CHARGE FE[
NO. DESCRIPTION OF WORK F
HOUSE SEWER OONN[OTIN TO REIMBURSEMENT FEE
PUBLIOSEWEp &m RECEIPT NO. DATE BY
HO-IT.N LrwER CONN Q TO
PRIVATE DISPOSAL SYSTEM I.SS
N A L BLDS.
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WORK TO HODS[SEWER IAO
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SEWER OR DISPOSAL SYSTEM ISS
DISCONNIECT AND ABANDON S[WER
AMD OR DISHISAL SYSTEM I OS CONNECTION DA
PITSNSEEPAGE PIT
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OF 00 ION L/iENGTH FROM
OWNERS PERMIT $ 1 pp cu P.L M.L.TO P.L .L
ALM-IORIZATION I TOTAL FEE G
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRAOTOR TO OONNECT THE ABOVE DESCBIBED EXISTING APPROVALS INSPEOTOR•8SIGNATURE DATE
DWELLING TO THE PUBLIO SEWER
SIGNED THIS CAY OF 19— NEW HOUSE SEWER
OWN[R OR CONNECT ADDITIONAL
OWNER8 AGENT BUILDINQ OR WORK
AD1)REBB SEPTIO TANK.SEEP.PIT(S)
AMD/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL F DRYWELL E]
CATION AND STATE THAT THE ABOVE IS CORREOT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STAT[ LAWS AyTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGED IBPO�AL SYSTEM
I HEREBY OERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABAIIDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN- ❑
ER OF THE ABOVE
DDESSGRRIBED RESIDENTIAL PROPERTY. SEEP.PIT(S)T OEESPOOLB
OF PERM SIGNATURITTEE r+/• rc/. 7I7•,rc5�s�,• QJr
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