HomeMy Public PortalAbout4972 SERENO DR_Sewer__ DEPAsrNI01NT OF COUNTY zNctugmm SEWER—SEWAGE DISPOSAL 1
DIVISION OF BUIIMING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANG313 ButLo1NB
WILLIAM J. FOX. CouMTY ENa1N[[M I ADORE88
FOR APPLICANT MFILL IN /' LOCALITY
BUILDING )//L Cfl0888T
ADDRESS
LOCALITY DISTRICT NO Rr0Y lot 1089m Ien, PPERRMITNO ,-
NEAREST 5 13 G / S
CROSS ST
EIV DATE 1 B .DATE
OWNER
MAIL
ADDRE88 NE ZONE OCCUPM�.�./ -
_v B�K qP�(B
A
CITY T RO � f
CONTRACTOR /
CO,IMP NO
ADDRESS Q
JOB MO
CITY- TEL NO TRUNK PERMIT NO
REBISTR ION NO e COUNTY
ROAD PERMIT NO
LEGAL
DESCRIPTION LOT NO STATE ENCROACHMENT
PERMIT NO
BLOCK TRACT S S'� _ / y�3 INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO OF BLDOS
NOW ON LOTCHARGES
USE OF
BUILDINGS ee=IR. CONNECTION CHARGE FE[
NO DESCRIPTION OF WORK FEE 41
HOUSE SEWER CONNECTING TO nnly
REIMBURSEMENT FEE
PUBLIC SEWER a s Sao V' RECEIPT NO I DATE BY
HOUSE 6EWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BL-ba OR EXCEPTION RECORDED
WORK TO HOUSE SEWER -- - - 100- __
AI
ALTER OR REPR EIB
XTING NO DATE BY
'
SEWER OR DISPOSAL SYSTEM 100
DISCONNECT AND ABANDON SEWER
_ AMD/OR DISPOSAL SYSTEM 1 co - CONNECTION DATA
SEPTIC TANK SEEPAGE I R L
PITS AND/OR GRAINFIELD 2.00 STATION 'Ll
� DEPTH /
CESSP OL— W LL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REF MCE
i/PPR11 L LOWER
TYPE ol
ECTIOM LENGTH FROM
OWNERS PERMIT s ( GG - CUR P L r L ra P L
AUTHORIZATION I TOTAL FEE -
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINB� APPROVALS INSPE -DATE
DWELLING TO TH PUBLIC $EWE
SIGNED THI AY OF LABANDON
USE SEWER
OWNERS AGENT BUILDING OR WORK
TANK, PIT(8)
ADDRESS _ R GRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- OL❑ DRYWELL
CATION AND STATE THAT THE ABOVE 18 CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY OflOIMAtlCEB AND STATE LAWS REPAI R�BEWER OR
REGULATING PLUMBING AND SEWERS E DISI LSYSTE■
AND/OR LIB EMBED IAB REQUITHAT RED BY LOS STERED N ECT PLUG AND
A 0 STATE OF CALIFORNIA OR THAT 1 Ar THE LEGAL OWN- ON HOUSE SEWER
ER OF THE ABOVE ESCRIBED B ENTIAL PROPERTY _ LL SEPTIITS) E88PoOLQ� 1.ft� ..{
SIGNATURE _
-OF PERMITTEE -
76A6I2D SAE SU 4/66