HomeMy Public PortalAbout9714 VAL ST_Sewer__ DEPABTMZNT OF OOUNTY ENGUMER SEWER--SEWAGE DISPOSAL 1
DIVISION OF BUELDING AND SAFETY PERMIT APPLICATION
OOUTiW OF LOS ANOELEB
WILLIAM J. FOX. COUNTY ENDINEER BUILOIIIO
AOGRESS ? 714 Pi IYA-1
FOR APPLICANT nTO FILL IN LOCALITY 7'
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OAUTY ��` D18T�NO A BEHIALRO PREST OSS ST rfRECEIVEMSY Rup Nr InspM40 DATEISSUEDNAI LNER Imo/' � 0- Kiln
ADDRESS y 7� �� oajj UBE ZONE OCCUPANCY BK YAP Pa
CITY TEL NO eS
CONTRACTOR � L d CO IMP NO
ADDRE
y... S JOB NO ---------
CITY U. G TEL NO �L �7 �Q TRUNK PERMIT NO
STATE
REGISTRATION NO COUNTY
ROAD PERMIT NO 3
LEGAL STATE ENCROACHMENT
DESCRIPTION LOTMO ,.��„r /SLK? PERMIT NO
BLOCK TRACT SA.w.♦� �/�e��0 �' INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT 11��NO OF SLOGS
L7NOW ON LOT .Z CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO DESCRIPTION OF WORK ,FEE REIMBURSEMENT FEE
HOU BEWER NN CTIMS O
PUBLIC BEWEll ® i 2.00 '0 RECEIPT MO
-CONNECTING O
PRIVATE DISPOSAL SYSTEM 1/0
HOUSE SEWER 00
CONNECT ADDITIONAL BLDG BR EXCEPTION RECORDED
WORK TO HOUSE SEWER 100 NO
ALTEROR IR REPAEXISTING . DAT[ BY
SEWER OR DISPOSAL SYSTEM 100
AND ORNDISPOSAL ABANDON EYSEWER 100 CONNECTION DATA
SEPTIC TANK.SEEPAGE PIT OR -
PITSAND/OR GRAINFIELD 2.10 STATION ey 4.O 4. DEPTH
C SSPGOL-DRYWELL
SPECIAL CONDITIONS ONLY 200 .Ifs r, MAN UPPEERREFEREYCE � r
iTTYP[OF OOONBMECTIBM._ L N TOHP LOM
OWNERS :PERMIT S I oo a
L ZZ
AUTHORIZATION TOTAL FEE I d I
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS IICBP CTOIGNATURE DATE
DWELLING TO THE PUBUG SEWER
516NED THIS___ __DAY OF __ __,_.'Iq_ NEW xouE s[w[p CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK BEEP PIT(8)
ADDRESS f! L _ .PI' , _..0 AND/OR DRAINFIELD
I HEREBY ACNNOWLEDGWL�EEDGDBE THAT I HA E REAR HI PLI- CESSPOOL ORYWELL0
CATION AND STATE THAT THE ABOVE 18 CORRECT AND GREE _
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR '
REGULATING PLUMBING ANDiSEWERS SEWAGE DISP64AL SYSTEM '
AND/OR LIR ECERTIFY
ED IAS REQUIRED BY T I AN PLOD ANGELERLY ESCOUNTYDISCONNECT PLUG AND ,
ANO STATE OF CALIFORNIA OR THAT I.AM THE LEGAL OWN. ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIS9 RESIDENTIAL PROPERTY BACKFILL SPTIC TANKS
- SEEP PIT(B)[] CESSPOOL
SIGNATURE J/yP
OF PERMITTE4.
TGAOUD 663 1/09