HomeMy Public PortalAbout9736 VAL ST_Sewer__ LoJ 1
DEPAIGTAffiVT OF COUNTY ENCUaV1 EB SEWER-SEWAGE DISPOSAL
DMSION OF BUnMING AND SAFETY PERMIT APPLICATION
COUNTY OF LOB ANOELEB I BUILDING ClWILLIAM J. FOX, COUNTY ENOIN[ER ADDRESS 73 6 r V/a-L
T_
FOR APPLICANT TO FI IN LOCALITY
ADDREAREST
UILDESS NG��'g�^ /e A/ CROSS RT F/
ADD RELolBS �/ //JJ G.. yC�
NEAREST DISTRICT NO A SERIAL NO PER� Y'IT NO C
Cfl0S8 RT J✓ /+S✓ J
flECEIVEOBY Readytefloepeptl" DATEIBRUED
OWNER
MAIL U�E OCCUPANCY MAP
ADDRESS I e� Pa
CITY TEL NO. //��,,,� 3 �f7(� L'^ 0
CONTRACTOR -(:tL CO IMP NO
ADDRESS Inte
p� JOB NO
CITY a TEL NO J, (yy�1ng0^ TRUNK PERMIT NO
STATE
REGISTRATION MO ` ROAD PERMIT NO
DESCRIPTION LOAL T pZ �/ STATE ENCROACHMENT
PERMIT NO
BLOCK TRACT, I � fj (�'( E APPROVAL
812E OF LOT GB
MOWNOOF ON13LDLOT CHARGES
USE OF
BUILDINGS CONNECTION CHA [
NO DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLICSEWER ® It 300 RECEIPT NODATE BY
HOUSE SEWER COMM90TINO TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ARDTTRONRL BLOB 00 EXCEPTION RECORDED
WORK TO HOUSE SEWER 100
ALTER OR REPAIR EXISTING NO DATE BY
SEWER OR DISPOSAL SYSTEM 100
DISCONNECT AND ABANDON BEWlRyyl CONNECTION DATA
AND/OR DISPOSAL SYSTEM 100
SEPTIC D ORTARK•SEEPAGE DRAINFIELDIT R 2.00 STATION C3 3-1-IA DEPTH
SPECIAL COCONDITIOWELL
NSNS ONLY 200 3L��!—� 07 M UPPE FERENCE bolimR
YPE� CONNECTION LENGTH FROM /
OWNERS PERMIT ; IEe;jo
Y TP- PcuRB P L ML TOP L 7
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTORS SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THISAD.AYOj_ 1 ) MEW HOUSE SEWEROWNER OR CONHEW ECT HOUSE SE IOMAL
OWNERS ADE _ BUILDINGORWORK
ADDflE88AMD/ORDHAEPTIC I Nf ELU IT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL 0 DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWEROR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AN PROPERLY REGISTERED DISCONNECT PLUG AND
AND STAll TE OFSCALIFORNIA AS UOR THIRED AT I AN THE Y LOS LEGAfL OWN ABANDON HOUSE HEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BAC FILLS TANK //(,�`�
SEEP PIT(S)[] CESSPOO F " "
SIGNATURE 1J
OF '/
TOAIKU 663 r/LT