HomeMy Public PortalAbout10644 ROSEGLEN ST_Sewer__ DEPAW-rMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
IL COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT J9 FILL LOCALITY
BUILDING / ' NEAREST
_ADDRESS / y �. Jr J►A CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST A S
CROSS ST.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL ADDRESS USEZONE OCCUPANCY MAP
- I I BK PG
CITY TEL.NO.
CONTRACTO
C6rl�O.
ADDRESS
JOB NO.
CITY TEL.NO. TRUNK PERMIT NO.
REGISTRATION NO. � � C� y� S
� ROAD PERMIT N0.
LEGAL
DESCRIPTION LOT NO. ;S [� STATE PERMIT NCROACHMENT
BLOCK TRACT � INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF BLOGS.
NOW ON LOT CHARGES
USE OF
BUILDINGS r CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER @ $ 3.50 RECEIPT NO. I 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
YI`PER
LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ 1 00 AN yB P.L. M.L.TO P.L.
AUTHORIZATION TOTAL FEE
IHAVE 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
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 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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND
ABANDON HOPLUG PLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SEEP.PIT(S)❑ CESSPOOLS
SIGNATURE �1rJ /,-_D�
OF PERMITTEE. ...-. ._-..-_._.....-.
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