HomeMy Public PortalAbout5433 SANTA ANITA AVE_Sewer__ ',-*DEPARTAEMqT OF COSY ENGIINE SEWER—SEWAGE DISPOSAL -
.r��IVISION OF BUILDING AND SAFETY PERMIT APPLICATION
-
�" _ COIINw OF LOS ANGELES
WILLIAM J. FOX. COUNTY EN131NEER BUILDING
- - ADDRESS
FOR APPLICANT TO FILL IN LOCALITY r�lwi � (A-477
BUILDING - .�s NEAREST
ADDRESS . GROSS ST.
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LOCALITY DISTRICT NO. SERIAL NO.. PERMIT NO.
NEAREST' _ —A A / S
CROSS ST /RECEEJD BY Ready for Inspection / DATEISSUED
OWNER _ - � � p�,j �°
MAIL ii USE ZONE OCCUPANCY BK MAP PG
ADDRESS !-al i✓
- = l r
TEL:NO.--�C
CONTRACTOR dogkcCO.IMP.N0.
ADDRESS &Z' 9v4A5ssj&
-_ JOB.N0.
CITY TEL.NO. "°�
_ TRUNK PERMIT N0. aJ
REGISTRATION NO. STATE � �_ f A
_ ROAD PERMIT NO.
LEGAL 0 STATE.ENCROACHMENT
DESCRIPTION LOT N0. _�1 PERMIT N0, -
BLOCK TRACT INDUSTRIAL -
812E OF LOT - NO.OF BLDGS. WASTE APPROVAL
NOW ON LOT CHARGEE n
USE OF -'r''3 ,�
BUILDINGS - CONNECTION CHARGE FEE � 02
NO.. DESCRIPTION OF WORK `FEE _ r REIMBURSEMENT FEE - -"
HOUSE SEWER CONNECTING TO - ^s
PUBLICSEWER ER. $ 8.50` _ .. RF.SEIYT N DATE
HOUSE SEWER CONNECTING TO = I l�.e�' ms I ;BY/fLI '_
PRIVATE DISPOSAL SYSTEM I.UO
CONNECT ADDITIONAL BLDG.OREXCEPTION RECORDED
WORK TO HOUSE SEWER - - 1.00 NO.
ALTER OR REPAIR EXISTING I DATE I BY
SEWER OR DISPOSAL SYSTEM ~1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PfT OR �. �
PITS AND/OR_DRAINFIELO 2.00 STATION DEPTH /
CESSPOOL—D RY W EL L
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
LOWER/
TYPE OF CONNECTION LENGTH FROM P 1
OWNERS •PERMIT -$ I Y) ne
Ge . P.L. M.L.TO P.L. °� O
� �. ',00
.AUTHORIZATION TOTAL FEE
I HAVE 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 HIS
. I _�° NEW HOUSE SEWER
T .__2,�._.._ AY OF_.-_ _"�
OWNER DRQ CONNECT ADDITIONAL
OWNERS G �...... _ . ..5�!L! BUILDING OR WORK
_.
SEPTIC TANK,SEEP.PIT(S).
ADDRESS....... ...__.......... _. __...._.._. AND/OR DRAINFI.ELD
1 HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APP.LI- CESSPOOL[] 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 PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT
ABANDON HOUSE AND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESlLDEljTj6t PROPERTY. BACKFILL SEPTIC TANKS I]
SEEP.PIT(S)r3 CESSPOOLS
SIGNATURE
OF'PERMITTEE..._
TGA6421) 663 1/53 /!�
'bA 642D-CE808-10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS _-,
LOCALITY - ---
NEAREST
FOR APPLICANT TO FILL IN CROSS ST_
OWNER _
DESCRIPTION LOT NO. •t ---r'--�--
.. ,�.. MAIL
BLOCK "y TRACT �" ADDRESS
' NO. OF BLOGS.
SIZE OF LOT
NOW ON LOT CITY - TEL. NO.
USE OF DISTRICTNO. GROUP MAP PROCESSED BY
BUILDINGS BK PS
+' �wzw....
CONTRACTOR
--`" CONNECTION DATA
__ADDRESS _
-
STATION DEPTH
CITY TEL. NO.
LIC
E REFERENCE
STA
NOTE .DESCRIPTION OF WORK FEECLASS MAN TOPE OF COU RB CONNECTION L � LEN
L TO P,;-.
-.--., LOWER -
LICENSE NO, _
M
HOUSE SEWER CONNECTING TO Y.
PUBLIC SEWER 0 $7,00 _ P.C.NO. �
_-- JOB NO.
SEPTIC TANK.SEEPAGE PIT OR CO.IMP.NO.
PITSN
AD/OR DRAINFIELD $10.00 --
HOUSE SEWER CONNECTiNG TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00i)J
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT
=WAV,, ,ASmNT RECORD,INSTR-NO,
DATE
WORK TO HOUSE SEWER $3.00 __ LL•
OVERFLOW SEEPAGE PIT.DRAINFIELD - --- >-
EXTN.,CESSPOOL.DRYWELL. $5.00 HWY.OR ST.WIDENING
"" A ,. .ABA NOON HOUSE ..,M ,,•"'- --_. --. -
SEWER Qjf:�.AL SYSTEM @ $3.00 _ STATE ENCROACHMENT
PERMIT NO.
MANHOLE ! $7.00 --INDUSTRIAL _ -. O
WASTE APPROVAL ,� t iLu
_ CHARGES
OWNERS PERMIT S 3 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
REIMBURSEMENT FEE
iHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING - APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS _ DAY OF 19-
NEW HOUSE SEWER
OWNER OR
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS _ SEPTIC TANK,SEEP,PIT(5)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAI NFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING CESSPOOL [IDRYWELL ❑ _
PLUMBING AND SEWERS. --
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSE1D AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRI SED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERM iTTEE - - SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION CK, M.O. CASH