HomeMy Public PortalAbout9825 VAL ST_Sewer__ ::::;1.,. APPLICATION FOR PERMIT 1
DIVISION OF B=ING AND SAFETY SEWER-SEWAGE.DISPOSAL
DBp�Ybaant of Como Eng ow
ComtT of LOB Eo9elw BUILDING
WM.J FOX. COUNTY ENINEER GAODREW
CAB W D aRIPPIN.Sur T or But LOCALITY
GAL FOB APPLICANT TO FILL IN N /I/ W
DESCRIPTION oin�sr CRIPTION LOT NO� Z / OWNER C 4�l / y N D
BLOC[ TRACT MAIL �(
ADORES!
NO OF BLOTS
SIZE OF LOT NOM ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP�j
CONTRACTOR T J BK /d
ADORES I BK PG
CO TION DATA
TEL NO (j� �j STATION DEPTH
r�7 STATEI MAIM EFERENCE
REGISTRATION NO 13 COUNTY P
TYOF CONNECTIO LENGTH FROM /
NO DESCRIPTION OF WORK FEE Y cu RB P L M L TO P L
HOUSE SEWER CONNECTING TO
PUBLIC SEWER ! S SOy j
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 DO _ �T
CONNECT ADDITIONAL BLDG OR CO IMP NO 3R JOB NO
WORK TO HOUSE SEWER 1 00 _
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-ORYWELL -- WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
-- CONNECTION CHARGE FEB
O��'$ P89DQIT f 1 00
AUTHOBMTION TOTAL PEE REIMBURSEMENT FEE
I HAVE THIS
TO CONNECT THEACTED ABOVEWITH THE DESCRIBEDH EXISTING CON-
TRACTOR TRACTORNG APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS D OF 19_ NEW HOUSE SEWER
OWNER OR / CONNECT ADDITIONAL
OWNERS AGENT LLIffY��7 BUILDING OR WORK
SEPTIC TANK SEEP,PIT({)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL C3AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AN PROPERLY REGISTERED AMD/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEUL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY BACKFILL S "
C TANK!❑
SEEP PIT S CESSPOOL!-0—
SIGNATURE
ESSPOOuSIGNATURE
OF PERMITTEE
WILLIAM J FOX.Cow"ENatP31FJER VAL®ATION
BY . P-2 O 7B�G�+jDM^i }1�AR30 4 2. 4.50 �
DEPUTY 7/ M 'r— / DEPUTY
BY By !! //`'^�'
0 DEPUTY DEPUTY