HomeMy Public PortalAbout9721 VAL ST_Sewer__ t Mst INSERTS
7@A:4 o° ° APPLICATION FOR PERMI -
COUNTY OF LOS ANGELES SEWER— SEWAGE DI O L 1
DEPARTMENT OF COUNTY ENGINEER
RUII.DING AND SAFETY DIVISIONem LDIKc
ADORERS /J
A•=T COD 1 .5100—d., LOCALITY VI
NEAREST qL93t
FOR APPLI IN CROSS ST LEGAL 1 'OWNERDESCRIPTION LOT NOBLOCK MAILDDRESS NO OF BLDG$ �LSIZE OF LOT NO ON LOT 1 j4"r NO.USE OI DISTRICT NO GRO YAP IQ a
BUI 1 OSCONTRACTOR R&D _cjADDRESS ge CONNECTION DATCITYere TEL NOC'l STATION DEPTH4TATE MANHOLE REFERENCE REGISTRATION NO J — COUNT7
No I
{1 DESCRIPTION OF WOR FEE
PUBLI CSs R CONNECTING TO t9 00
ER TYPE OHNE ON LENGTH FROM'
SEPTIC TANK SEEPAGE PIT OR T CURB Pl.
Y L TO P
PIT$AND/OR DRAINFIELD S 00
OVERFLOW SEEPAGE PIT DRAINFIEID 00
X CE 0 L f2
HOUSE EWER CO NNECTI NG TO P C NO
PRIV T 0 POSA N11S�II� tl CO IVP NO JOB NO
WORK TO XODDSEISEWEBLDG ORodoo IV
TRUNK PERMIT NO ROAD PERMIT NO O
AR PAIR OR ABANDON HOUSE 1 STATE ENCROACHMENT - Ol
- PERMIT NOQ
INDUSTRIAL {aPrC7j{
WASTE APPROVAL
CHARGES
Oy�IN�'S PERMR p D CONNECTION CHARON FEE
AUTHORMATION r TOTAL FEE REIMBURSEMENT FEE
IHAVE TRACTOR TO CIONNECT THE ABOVE DESC THE EXIEINNG DWELLAMED COW
6 APPROVALS /D TE INSPECTOR S SIGNATURE
TO THE �� I
SIGNED THI 8 NEW HOUSE SEWER 1 .n 1�OWNER
OWNERS AGE /' CONNECT ADDITIONAL V �����IT 11
BUILDING D WORK
ADORES fEPTIC TANK SEEP PIT(S)
AMD/OR DRAINII ELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION _
AND STATE THAT THE ABOVE IS CORRECT AND AOREE TO COMPLY CESSPOOL 13 DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY L09 ANGELES COUNTY AND STATE OF ABANDON L HOUSE SEWER
CALIFORNIA OR THA I AY THE A OWNER OF THE.
DESCRIBED REST OPERTY BACKFILL SE C TANKS
910NATURE SEEP PIT(S) CESSP00
OF PER
®r VAI.IDATIOW"% ROBERT A WOOD , —
Ct. ■ o CUM SUPERVISING MECHANICAL WOINEE11
LACO2 5 4 3Q1 ALG 3 1 0 0 5.00- o
r
DEPAUTAIENT OF COUNTY ENG[NEEFi SEWER-SEWAGE DISPOSAL 1
DIVISION OF HUILMING AND SAFETY PERMIT APPLICATION
0OUN'1T OF LOS ANGELE-S
WILLIAM J. FOX, COUNTY EN13INEER BUILDING
AODRE88 R�
FOR APPLICANT O FILL IN LOCALITY
BUILDING `�� NEAREST
ADDRESS J JJJ CROSSST Z
LOCALITY _ �DI Gf DISTRICT NO SERIAL NO /� 'P7ERMIT NO
NEAREST � J _/_ J � yWi� A pC / 630 S
CROSS
8T i agN K/ RE�IV�D BY fletOY for IwpMbE DATE ISSUED
OWNER co 0 --/� �-'�T �-7_S�
MAIL USE 30NE OCCUPANCY BKS PB
ADDRESS
CITY TEL N0. �)?in I
-
CONTRACTOR IMP NO
ADDRESS 8 0 V ��IT S JOB NO
CITY V / AftQw40TELNO _ TRUNK PERMIT NO
REGISTRATION NO STAT6
Y ROAD PEgMl7 NO r -�1
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO c_ PERMIT NO _
BLOCK TRACT � INDUSTRIAL
WASTE APPROVAL
812E OF LOT NO OF BL
MOW ON LOT
CHARGES
USE OF
BUILDINGS CONNECTION CHARGE E
NO DEBCRIPTI N OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTI-NO-T
PUBLIC SEWER ® i L50 RECEIPT NO TE BY
HOUSE SEW[ N INS TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITION BLDG O EXCE ION RE RDED
WORKTO"OUSE SEWER IDG
ALTER ON REPAIREXISTING NO r DATE\ BY
SEWER OR DISPOSAL SYSTEM 100 l
DISCONN15CT AND ABANDONSEWER CONNECTION DATA
AND OR DISPOSAL SYSTEM 100
PITS AND Op DpA NFIELPAGE D R 3.00 STATION `7-7 4-L?i DEPTH
ELL
SPECIAL CONDITIONS ONLY 200 "I ` OMMA HON BpEF
L[ ERENCE
W R�'� LOWER
TYPE OF CONN ECTIOM LENGTH FROM
OWNERS PERMIT $ 1 00 'X^ CURB -ILL. M L TO P L
AUTHORIZATION TOTAL FEE - a
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR B SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS DAY OF—_ 19_ NEW HOUSESEW[R ly/n
OWNER OR [� COHNECTADDITIONAL
OWNERS AO BUILDINGEPTICTANK WORK
SEP
ADDRESS
AND/OR GRAINF ELD IT(B)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE HEAD THIS APPLI. CESSPOOL[] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND-STATE LAWS ALTER REPAIR SEWERON
REGULATING PLUMBING AND SEWERS SEWAdE DISP04XL SYSTEM
1 HEREBY CERTIFY THAT I AN PROPERLY REGISTERED t
AtlD/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN. ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED R[ NTIAL PROPERTY BA A
SIGNATURE SEEP PIT(S)0 CESSPOOL�
IG0
OF PERM ITTEE MA
T6AM2A 682 7/68