HomeMy Public PortalAbout10635 ROSEGLEN ST_Sewer__ DEPAItMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 7
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION 1
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING / -+ NEAREST
ADORE �/I G+ �]' CROSS ST.
b
LOCALITY / DISTRICT NO. SERIAL NO. PERMIT NO.
`,/
NEAREST 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.IMP:NO.
ADDRESS
JOB NO.
CITY TEL.NO.
TRUNK PERMIT NO.
STATE
REGISTRATION NO. ❑ COUNTY ROAD PERMIT NO.
LEGAL �' / STATE ENCROACHMENT
DESCRIPTION LOT N0. /_ PERMIT NO.
BLOCK TRACTS t' INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF BLDGS.
NOW ON LOT CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLICSEWER 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 I.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
tl'PFER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ 1 00 Y. CURB P.L. M.L.TO P.L.
AUTHORIZATION TOTAL FEE "/ !,
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..........._..........................I9.---._ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT...................................... -------- BUILDING OR WORK
..--••-------•----.-..-._.._---....--._........-------
SEPTIC TANK.SEEP.PIT(S)
ADDRESS.
- - - - - - - - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL E] 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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
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
❑
OF PERM
SIGNATURE // f .fes 1=wA-
SEEP.PIT(S)Ej CESSPOOLS[
-,. ...--- -....l-_...--- ---��`�:..._J��!-=)_.:'-=--'--•-- ..----
76A642D 663 1/53