HomeMy Public PortalAbout10645 ROSEGLEN ST_Sewer__ ]DIEPAICTNOEM OF COUNTY ENCO2 EM SEWER SEWAGE DISPOSAL 1
DIIISION•OF BUILDING AND SAFETY PERMIT APPLICATION
OOUNTY OF LOS ANGIU, S
WILLIAM J. FOX, COUNTY EHvin]EER BUILDING b �o S l �. �t
ADDRESSN
FOR APPLICANT TO RLL IN LOCALITY
BUILDING ���� I�, .� oROasST.
ADDRESS
LOCALITY DISTMOT NO. SERIAL NO. PERMIT M0.
NEAREST �5— A / 15-1-Y -S-0S
OROSB ST. fV BY Ready hr luradko DATE ISSUED
OWNER
MAIL
ADDRESS f USE ZONE 0 ANCY MAP BK P9
OITY TEL NO. L
OO IIT RAOTO G t
ADDRESS
JOB NO.
CITY / TELNNOo. Q, '3� TRUNK PERMIT M0.
REGISTRATION N0. 6 I��` ► e-Q ROAD PERMIT NO. `
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT M0. 1 / PERMIT M0.
BLOCK TRACT INDUSTRIAL =
SIZE OF LOT NO.OF BLDG R. WASTE APPROVAL
NOW ON LOT OHA11bE#
USE OF
BUILDINGS CONNECTION OHARQE FEE
M0. DE.EICRIPtIEN OF WORK FEE
-House[EWER OONNECTINA TO REIMBURSEMENT FEE
-T
PUBLIOSEWER 0 $ SSS gE0E1PTM0. ATE BY
OUSETIER 00 11111 EOTI NG TO
PRIVATE DISPOSAL SYSTEM IJNI
Dom NEOT OM BLDS 0 ]EXCEPTIONDED
WORK TO HOUSE SEWER LN
AL EIf7tr REFAI E)C7 NO ATE BY
SEWER OR DISPOSAL SYSTEM IJMI
1800NMEOT ANb ABANDON S]EWER
AND OR DISP.%A SYSTEM IM OONNECTION DATA
SEPTIC TANEPAGE PIT OR
PITS ANDOR DRAINFIELD 2AO STATION J-4- D DEPTH /
SPECIAL CONDITIONS ONLY im MANHOLE REFERENCE /,'
VV e LOWER
TYPE OFA$ECTIOM � MEL TOP FROM
OWNERS PEPmrr $ 1 00
AUTHORIZATION TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRICTOR TO GONNEOT THE LIO SEWER VE DESOBIBED EXISTING APPROVALS IN8PECTOR'SSIGMATURq DATE
DWELLSIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR OONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,8EEP.PIT(8)
AMD/OR GRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL E] DRYWELL
CATION AND STATE THAT THE ABOVE IS CID RREOT AND AGREE
TO COMPLY WITH ALL DOUNTY ORDINANOES AND &TATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS BEWARE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PNOPERLY REGISTERED
AMD/OR LIOEN8ED AS REQUIRED BY LOS ANGELES COUNTY DISOOMNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ABANDON HOUSE 8EWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. C EP 0 AM S[]
SIGNATURE r SEEP.PIT(8)� CE88POOL8
OF PERMITTErl
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