HomeMy Public PortalAbout9641 VAL ST_Sewer__ S R90FA6 2 12 54 APPLICATION FOR PERMIT 1 i9AY
MSION OF BUMDING AND SAFETY SEWER—SEWAGE DISPOSAL
D.paren.nt of Cormty EngfnBBY
County of Im Aagates BUILDING
WM J PDX, COUNTY ENGINEER ADDRESS
CAGGATT D GRIFFIN Sur T or Bu1LDINa LOCALITY f
FOR APPLICANT TO FELL IN NEAREST
CROSS!T
LEGAL
DESCRIPTION LOT NO OWNER ` 1
BLOCK TRACT TAIL 1L
_ADDRESS 7
NO OF SLOGS .� yy
SIZE OF LOT NOW ON LOT T!L V 70 J 19 Y
U3!OF
BUILDINGSDI ICT 0 I OUP MAP
CONTRACTOR T 5 T BK PO
ADDRESS A/wCOIMC/TION DATA
CI TEL �y .� STATION DEPTH
ATE YA HOLE REFERENCfi
REGISTRATION NO ❑ COUNTY OBBRIr �W LOWER
TYPE OF CONNECT 1 LENG FROM ,
NO DESCRIPTION OF WORK FEE Y CURB P L Y L To P L
HOUSE SEWER CONNECTING TO f
PUS
LIC SEWER 0 $ 330
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR CO IVF NO JOB NO
WORK TO HOUSE SEWER 1 00 __
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 100 STATE ENCROACHMENT
SEPTIC TANK,SEEPAGE PIT OR -- PERMIT NO
PITS AND/OR DRAINFIELD Z DO INDUSTRIAL
CESSPOOL•DRYWELL -- WASTE APPROVAL
SPECIAL CONDITIONS ONLY Z 00 CHARD
OWNEIYS
CONNECTION CHARGE FEE FEtti�T s o0
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE aWA
1 HAVE DATE CONTCTED1
TRACTORTHIS TO CONNECT THEABOYEWITDESCR BEO E%ESTIXDA OW EL LON
II G APPROVAL DATE INSPECTOR 9 SIGNATURE
TO THE PUBLIC SEW R _
SIGNED THI AY OF IB,j S HOUSE SEWER „ m
OWNER OR L CONNECT ADDITIONAL
OWNERS G N BUILDING OR WORK
SEPTIC ANKADDRESS A N
'
/
O
RT
DRANTULDPIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READW. .'
i APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ASOVQ 19 CORRECT AND A E 70 COMPLY
WITH ALL COUNTY ORDINANCE! AND !TATE LAWS REGULATING
PLUMBING AND SEWERS ALTER, DISPOSAL SEWER
OR
SEWAGE 019POSAL SrlTfiY
1 HEREBY CERTIFY THAT 1 AN PROPERLY pNTYA RE0 AND/OR DISCONNECT PLUG AND
LICENSED A9 REOHAED BY LOS ANGELES COUNTY AND E AB OF
CALIFORNIA SI THAT I AY THE LEGAL OWNER OF TXfi ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL ► 6RTY BACKFILL SEPTIC TANK!❑
bfiEF ►ITB CESSPOOLS
SIGNATURE
OF PERU Il
WILLIAM J.FOX,CouNTr ENotNEOR VALIDATION
By 7 q 8 0P SEP 8 4 4_.50 m
DEPUTY DEPUTY
By er
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m DEPUTY DEPUTY