HomeMy Public PortalAbout9750 VAL ST_Sewer__ 21214 APPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Depormtent of Conicity Engln"t
C, mtT of Lo■ Angeles BUILDING
WM J FOX COUNTY ENamsxR ADDRESS
C:AGBATT 0 GRIPPIN,MMP T OF MUILDING LOCALITY
FOR AP7
PLICANT TO FILL NEAREST
CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK TRACT MALZOP
AIL
ADDRESS
NO OF SLOGS
SIZE OF LOT/ NOW ON LOT CITY TEL NO
USE OF
BUILDINGS Q DISTRICT NO GROUP MAP
CONTRACTOR
ADDRESS /J CONNECTION DATA
CITY TEL NO .4r, STATION 13 DEPTH /
STATEMANHOLE REFERENCE
REGISTRATION NO ❑ COUNTY • UPPER JrWSY
TYPE OF NNE ION LENGTH FROM
NO DESCRIPTION OF WORK FEE Y RBS P L M L TO P L
HOUSE SEWER CONNECTING TO ? p
PUBLIC SEWER W S S SO J _
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR CO IMP NO ;zJOB NO
WORK C HOUSE!EWER 100
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL•DRYWELL -- WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 C
CONNECTION CHARGE
OWNEWS PERMS f 1 �00
AUTHORIZATION TOTAL FEE J 5 REIYBUR46 T FE6
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN MANED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED UISTING EXISTINGDWELLI APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIs� AY OF 19— NEW HOUSE SEWER S1�Ss
OWNER 0 CONNECT ADDITIONAL
OWNERS NT, BUILDING OR WORK
ADORE!! I SEPTIC TANK SEEP,PITS)
AHD/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL[I DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY OR
AND STATE LAWS REGULATING ALTER REPAIR, SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AMD/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY D STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AN THE LEGA OWN THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY
SEEP PIT(S)SEPT C TANK!❑
SEEP PITS CElEP0/
SIGNATURE
OF PERYITT
WILLIAM J FOX,CouNFrifIENasmum ATION
CO3 7 O On W'7:3 4 4.S 0
by BY ' ! _
DEPUTY �i{,+A �DEPUTY
BY ® ta'1
0 DEPUTY DEPUTY