HomeMy Public PortalAbout9805 VAL ST_Sewer__ 4O
sonAPPLICATION FOR PERMIT 1
DrMON OF R WING AND SAFETY SEWER-SEWAGE DISPOSAL
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WM J FOX. COUNTY ENGIN[DI ABU
CA¢BArT D GRIFFIN,El P OF BUH.DIMY LOCALITY
FOR TO IN NIIARREsr /
LEGA
oE9CRIPTION LOT 0 OWNER
BLOCK TRACT NAIL
ADDRESS
NO OF BLOBS
SIZE OF LOT NOW N LOT CITY TEL
USE OF
BUIL INGE DISTRICT NO GROUP MAP
BK PG
CORTRACT00.
ADDRE49 CONNECTION DATA
CI // TEl N STATION OEPTX
REGISTRATION NO WO J T 5— ❑ COUNTY MANHOLE REFERENCE UPPER
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER !SO
CURB P L Y L TOP L
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR P C NO
WORK TO HOUSE SEWER 1 00 CO IMP NO JOB NO
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 100 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS ANO/OR GRAINFIELD 00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY t 00 CHARGES
OWNER'S
FEHMRS 1 OD CONNECTION CHARGE FEE
AUMORMTION I TOTAL FEE elREIMBURSEMENT FEE
IHAVE TRACTORHIS DATE ToCONNECT THEABOVE DESCRIBED EXICTED WITH THE STINGA MED I
DWELLING NG APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS AY OF 19— NEW HOUSE SEWER ,
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT Z ;e BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR GRAINFIELD
JHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL[IDRYWELL❑
ASTATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS R
O
EWER ALTER REPAIR,S
1 HEREBY CERTIFY THAT 1 AN PROPERLY REGISTERED AND/OR SEWAGE DISPOSALSEWERSYSEM
OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AY THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SE C TANKS❑
SIGNATURE SEEP PITS CnSPOOL3
OF PERMITTEE
WIWAM J.FOX.CouNTY FoUgmER VALIDATION R A WOOD,CHIEF PLBo. INBF¢croR
_I.ACpO 3 0 69i JAN 10 4 A 450 2
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