HomeMy Public PortalAbout9831 VAL ST_Sewer__ ✓i[!312 14 APPLICATION FOR PERMIT 1
DMSION OF BUMDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of Comte EBglnoer
Comte of Lw Angel" BUILDING
WM J FOX. COUNTY ENGINEER ADDRESS
CABBATT n GRiFrIN Bur T Or Bu1LDIMG ` LOCALITY
FOR APPLICANT i0 FIIJ. IN NEAREST
CRO, ST ST
LEGAL
DESCRIPTION LOT NO ! �s OWNER
BLOCK TRACT MAIL
ADORE!!
NO OF BL009
SIZE OF LOT NOW ON LOT CITY TEL N
USE OF
BUILDINGS DISTRICTNO I GROUP qNAPCONTRACTOR C �rw.
ADDRESS s-vf�� yf /,)Vo CONNECTION DATA
CITY ,_J TEL NO T.1 J/ STATION 9t-ea J- DEPTH
O STATE r O MANHOLE LOWER REGISTRATION NO �7 6_ ��/ ❑ COUNTY ✓ ��
TYPE OF CONNECTION LENGTH FROM O
No DESCRIPTION OF WORK FEE -►"' CURB M L To P L
HOUSE SEWER CONNECTING TO
.PUBLIC SEWER ® S 3 90 _.
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR CO IMP NO JOB NO
WORK TO HOUSE SEWER 100
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 100 TRUNK PERMIT NO ROAD PERMIT NO 3 470
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
_ PITS AND/OR DQA1NFIELO 2 DO INDUSTRIAL
CESSPOOL-DRYWELL -- WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
II
CONNECTION CHARGE FEE
OWNER'S PERMIT S 1 00
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON ��n
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR 9 SIGNATURE
TO THE PUBLIC SEWER r
SIGNED THIS DAY OF NEW HOUSE SEWER Z-�' T-
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT ol BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(!)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL[] DRYWELL❑
AND STATE THAT THE ABOVE IB CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWER! SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AY PROPERLY REGISTERED AMD/OR
LICENSED AS REQUIRED BY LOB ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY BACKFILL EC TANKS[['TI
/ SEW PITSEP CESSptj
SIGNATURE V
OF PERMITTEE
WILLIAM J FOX,Courerr EP 1 ¢art VALIDAIION
BY ._ 0223 E'CM-,_4_� 4_ 45_ 0
DEPUTY �" 'F� DEPUTY
BY BY
0 DEPUTY DEPUTY