HomeMy Public PortalAbout10628 ROSEGLEN ST_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
C(vJNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT Ta: ILL IN LOCALITY
BUILDING NEAREST
ADDRESS MO CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEARESTA S
CROSS ST.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER ed
MAIL
ADDRESS 17,2 USE ZONE OCCUPANCY BK MAP PG
CITY TELAO. c
CONTRACTOR
8®lMIl4�N 0.
ADDRESS
JOB NO.
CITY Q/L„L� 1 TELAO. ,tJl ��� (� TRUNK PERMIT NO.
REGISTRATION NO. j' .. STATE
COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. R STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT /f INDUSTRIAL
• !f WASTE APPROVAL
SIZE OF LOT NO.OF BLDGS.
NOW ON LOT CHARGES
USE OF s"
BUILDINGS �,-
e-.? r'— CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLICSEWER 3.50 RECEIPT NO. DATE 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
11RUER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ I 00 Y. CURB P.L. M.L.TO P.L.
AUTHORIZATION TOTAL FEE -f 5 G
1 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 0R WORK
SEPTIC TANK.S P.PIT(S)
ADDRESS......................- - -.............. .............
- .... - - - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL E DRYWELL I]
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 DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABO`VEE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS[-]SIGNATURE 7� /1 SEEP.PIT(S)(-] CESSPOOLS
OF PERMITTE :. _G.f+l.e� ..e.
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