HomeMy Public PortalAbout10666 ROSEGLEN ST_Sewer__ DEPAti7_2dMqT OF COUNTY ICNGUNEES SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILMING AND SAFETY PERMIT APPLICATION
09UNW,OF IAS ANGlrI..EB
WILLIAM J. F [ An OX. CouNry EHOIN[ R AnUILDINe
FOR APPLICANT TO FILL IN LOCALITY
BUILDEING 98 10666 P CROW AREST
ADDROW ST.
LOCALITY Temple ulty DISTMOT M(L SMAL NO. PERMIT NO.
No"STS . El Mm t o Ave. A
/BE IVfi BY R.a*fir l..a.d1.. DATE ISSUED
OWNER p•T � Un Nutt I
ADDRESS ?.7* San (�abrial Bldd.MAIL USfiZONE OCCUPANCY YAP
�. BK PQ
CITY SalmGebriel TELN04T �4364I
CONTRACTOR L. D. & M. Constr. Co. eoJ.M. No. �,,
ADDRESS 21 W. W1B t8ria Ave.
JOB N0. 5—:5—
CITY Ar08dia TELNO. DO 6 2238 TRUNK PERMIT N0.
STATE
REQISTRATION 110. 113613 0 42 18 COUNTY ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. 1' `. ', PERMIT NO.
BLOCK TRACT 19189 INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT N0.OF BLDGS
NOW ON DT 2 OHARG
BUE DINGS Res. & Garage CONNECTION CHARGE FEE
N0. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
1 PUBLIC SEWER • I alfa RECEIPT NO. DATE BY
HOUSE N G TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BL Ott EXCEPTION 4,LCORDED
WORK TO HOUSE SEWER IAO
REPAIR NG
AE
SEWER OR DISPOSAL SYSTEM 1 0a —0.
DATE BY
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM I.00 CONNECTION DATA
SEPTIC TANK. EPA P R /
PITS AND/ORDRAINFIELD Z-0a STATION .� G. O DEPTH
OL—D L
SPECIAL CONDITIONS ONLY Loa _ Y NIHOLERREFERENCE =
TYPE OF CONNEC ONLENGTH FROM /
OWNERS PERM T $ 1 OO Y`. t„tR8 PA_ L�Y.L TO P.L. d
AUTHORIZATION I TOTAL FEE 41 w
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
OONTRAOTOB TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS I NSPECTO"SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19— NEW HOUSE SEWER 5a rr, c - ¢
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK!(,BEEP.PIT($)
ADDRESS AMD/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL[-] DRYWELL
CATIONAND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO 00MPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAs�E DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 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 AN THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. 13AOKFILL SEPTIC TANKS
n []
SIGNATURE SEEP.PfT(S)� CEGS"OL`�
OFPERMITTEE Le • M• Amatr. +0.