HomeMy Public PortalAbout10673 ROSEGLEN ST_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING / ,✓ NEAREST
ADDRESS [D ��r / rQ e�� C. CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST A . S
CROSS ST. ,.Lem--�'%�...- " r.'-d...
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL
ADDRESS �" {� t-- USE ZONE OCCUPANCY MAP
BK PG
CITY TEL.NO
CONTRACTOR (*->L (Ag.,
ADDRESS
/ JOB NO.
CITY T TEL.NO. , 20v TRUNK PERMIT NO. —-
REGISTRATION NO. �/j e%"c:sg0 STATE
ROAD PERMIT NO.
LEGAL /
DESCRIPTION LOT NO. STATE ENCROACHMENT --
PERMIT NO.
BLOCK TRACT INDUSTRIAL
LLL!!! WASTE APPROVAL
SIZE OF LOT NO.BF BLDGS.
NOW ON LOT CHARGES
USE OF
BUILDINGS �-/— CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK F
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER Q $ 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 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION T( DEPTH
CESSPOOL—DRYWELL t
SPECIAL CONDITIONS ONLY 2.00 /-I / MANHOLE REFERENCE
WNalR LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT ; I 00
CU%B P.L. M.L.TO P.L.
AUTHORIZATION I 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..........................._..._......19...-... NEW HOUSE SEWER .-
OWNER OR CONNECT ADDITIONAL
- -
OWNERS AGENT........................................... . BUILDING OR WORK
SEPTIC TANK.SEEP.PIT(S)
ADDRESS - - ... - - AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL❑ DRYWELL F]
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
1 HEREBY CERTIFY THAT I 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 AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE �,/�,D /�j ,a+a, / SEEP.PIT(S)0 CESSPOOLS
OF PERMITTEE-__S ._._ f��_" �ljr �.Co�.
76A642D 663 1/53 iy ,#,H_