HomeMy Public PortalAbout10660 ROSEGLEN ST_Sewer__ DEPA C iK1CNT of COUNTY ENE02UMB SEWER—SEWAGE DISPOSAL
DIVISION OF BUII.DING AND SAFETY PERMIT APPLICATION
00'G T OF I.O8 ANGEI.H�
WILLIAM J. FOX, COUNTY ENOIN¢[R BUILDING
ADDRESS
FOR APPLICANT T LL IN LOCALITY
BUILDING
l�y L� NEAREST
ADDRESS �. t' -C
ROSS 8T. {�( G
LOCALITY �S DISTRICT N0. SERIAL NO. PEBMIT NO-
NEAREST
0.NEAREST A zS
CROSS 8T,
c� RECEIVEQ BY aBlity far lsaNstlsa DATE ISSUED
OWNER ✓ / (�
MAIL
ADDRESS r USE ZONE 00CUPANDY YAP
BK PG
CITY TELNO. f – /
CONTRACTOR CftMPF IO. `• 7 �`
ADDRESS f lJ
JOB NO.
CITY ��� TELNO. d ��
TRUNK PERMIT M0.
REGISTRATION NO. (� TE
1/y ROAD PERMIT NO.
LEGAL 7 p _
STATE CROAOHYEKT
DESCRIPTION LOT NO. Je) PERMIT NO.
BLOCK TRACT ,Q� INDUSTRIAL
: i i?—/ WASTE APPROVAL
SIZE OF LOT NO.BF BLDGS.
NOW ON LOT CHARD
USE OF
BUILDINGS GONNECTION CHARGE FEE
N0. DEBE:RlPtION OF WORK FE
HOUSE SEWER CONNECTING TO REIYBURSEYENT FEH
PUBLIC SEWER 0 $ am RHOEIPTMO. DA BY
HOUSE d�ERCONNEOYING TO
PRIVATE DISPOSAL SYSTEM IJIO
IONAL BL (BLD(L OR EXCEPTION QEOO
WORK TO HOUSE SEWER 1.00
E t�OR REPAIR M NO DAT BY
SEWER OR DISPOSAL SYSTEM ISO
DISGONNECT ANDABANDON SEWER
ANDOR DISPOSAL SYSTEM I.�O CONNECTION DATA
OTAN FPAGE PIT OR
PITS AND/OR DRAINFIELD 2J?0 STATION 7 O DEPTH t; /
L
SPECIAL CONDITIONS ONLY 2-mS/ Y NUHOLE PPER REFERENCE beSaR
TYPE OF OONNE (ON LENGTH FROM
OWNERS PERMIT $ 1 00 '14- 8"Rlr P.L L�M.L.TO PT
AUTHORIZATION TOTAL FEE Z1 L4-0
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
OONTRAOTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVAIS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIO SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWERLT '
OWNEI} OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK SEEP.PITS)
ADDRESS AMD/OR1)RAIN FIELD
I H[REBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL[-] DRY-WELL
CA
TIONAND 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 O ALSYSTEM
1 HEREBY CERTIFY THAT 1 AY PROPERLY REGISTERED SEWAGE DISPDISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AN THE LEGAL OWN.
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL I ANK ❑
SIGNATURE � p BEEP.PIT(S)E] CESSPOOLS E]
OF PERMITTE 6 4- 9 '
TGABUD OU 1/1% ``
y