HomeMy Public PortalAbout9157 WEDGEWOOD ST_Sewer__ •DEPARTMENT OF COIINTY.ENGUgEER SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY
PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT F LL IN LOCALITY
BUILDING NEAREST t'
ADDRESS W?40 CROSS ST.
LOCALITY ,� ��� a.6 V_ DISTRICT NO. • SERIAL NO. PERMIT NO.
NEAREST w � • A3 4 967
GROSS ST. ECE VED B. Ready for Inspeotlon DATE ISSUED
OWNER~ 1S ;/ `'
MAIL USE ZONMAP
E OCCUPANCY BK PG
ADDRESS ,rE �� 61
CITY�Y�re d•«!riC ;d l EL.N � � I
CONTRACTOR
r --R--% CO.IMP.NO: -`+`—
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ADDRESS
JOB.N0. I
CITY _ ��! _� tiTEL.NO. �' TRUNK PERMIT N0. `�"-
TATE
REGISTRATION N0. " a' COUNTY ROAD PERMIT N.O. "'c.......EGAL
-
DESCRIPTION LOT NO. �''_� NZ f,(��Jar? n r �.5 STATE.ENCROACHMENT•� -�,--�
/ -" PERMIT NO.
BLOCK' TRACT ' WASTE APPROVAL
SIZE.OF LOT NOWCON LOT CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEES
NO. DESCRIPTION 'OF WORK -FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ ; 3.50 S vco) RECEIPT NO. ,9 DATE_ BY
HOUSE SEWER CONNECTING TO I J
PRIVATE DISPOSAL SYSTEM 1.00 q
CONNECT ADDITIONAL' BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00 NO. � I BY
ALTER OR REPAIR EXISTING_. _
DATE `
SEWER OR DISPOSAL SYSTEM 1.00 1
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
—SEPTIC TANK,SEEPAGE PIT OR t�- h — - _
PITS AND/ORDRAINFIELD• 2.00 STATION [JJ / D'EPTN
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY. 2.00A* +'F'� M UPPER REFERENCE
TYPE OF CONNECTION LENGTH FROM
OWNERSPERMIT ; � I 00 CURB.+ • P.L. - M.L.TO P.L. f '
. -
AUTHORIZATION TOTAL FEE 1 orz
t HAVE THIS DATE CONTRACTED WITH THE HEREIN .NAMED "
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING ' APPROVALS- INSPECTOR'S SIGNATURE DATE
DWELLING TO THE. PUBLfC. f-�
SEWER
77
SIGNED THIS. ... AY OF`�._��I.lc�' d� _.._..19. - NEW HOUSE-SEWER c�G..::. : `ez�3
rl 11 CONNECT ADDITIONAL
OWNER. OR '�;, f" m BUILDING OR WORK
OWNERS AGENT... yF R ' tom..
1
SEPTIC TANK,SEEP.PIT(S)
ADDRESS..........._ AND/ORDRAINFIELD.
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL[] DRYWELL O
CATION AND STATE.THAT'THE ABOVE'IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER.REPAIR.SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSA4SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT
ABANDONHOUSE SEWER
AND STATE OF CALIFORNIA OR THAT•F AM THE LEGAL OWN-
ER OF THE ABOVE SCRIBED E PROPE BACKFILL SEPTIC TANKS
SEEP.PIT(S)[] CESSPOOLS
SIGNATURE
OF PERMITT.E _, _ �:=s-
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