HomeMy Public PortalAbout5226 WILLMONTE AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING NEAREST
ADDP,ESS CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST A --. _ — J
CROSS ST.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIADD USE ZONE OCCUPANCY Ar IW
ADDRESS _ I I BK PG
�fA
CITY TEL.NO.
CONTRACTOR CO.IMP.N0. _ l
ADDRESS
JOB NO. -- -
CITY TEL.NO_
TRUNK PERMIT NO.
STATE
REGISTRATION NO. COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. STATE ENCROACHMENT _.-
PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF BLDGS.
NOW ON LOT CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO — REIMBURSEMENT FEE
PUBLIC SEWER @ $ 3.50 RECEIPT NO. DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO_ ] DATE I Br
SEW_ER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION _ DEPTH
CESSPOOL—DRYWELL
•
SPECIAL CONDITIONS ONLY 2.00 MANN,nLF REFERENCE-
_i 'UPPER.. LIQ
TYPE OF_M`2NECTION LENGTH FROM —
OWNERS PERMIT # 1 00 "cURR _-- M.L.TO P.L. _
AUTHORIZATION I TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THE PUBLIC SEWER APPROVALS INSPECTOR'S SIGNATURE DATE
SIGNED THIS_..--------- .-DAY OF------.-------.---------..•._._------.14__...:_ NEW HOUSE SEWER ! }
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT.-..-----__--------- --...._.------.-- BUILDING OR WORK
ADDRESS.--- -------_. SEPTIC TANK,SEEP.PIT(S)
- - -.._......__....... _ AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL[] DRYWELL
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 DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- _
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SEEP.PIT(S)o CESSPOOLS 0
SIGNATURE
OF PERMITTEE- -- _..
76A642D 663 1/53 ayc