HomeMy Public PortalAbout5233 WILLMONTE AVE_Sewer__ DEPAlt'TMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 9
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION j
COUNTY OF LOS ANGELES BUILDING
WILLIAM J. FOX, COUNTY ENGINEER j ADDRESS _ d
FOR APPLICANT TO FILL IN LOCALITY
BUILDING NEAREST
ADORESS� j s —_� Y r C CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST `
CROSS ST. LE a _Y' j±. / _r..L _ —
RFCEiVED BY Ready for inspection � DATE ISSUED
OWNER g
MAIL USE ZONE i OCCUPANCY MAP
ADDRESS I2K PG
yr..
CITY t C r TEL.NO. :? t Y-4 `l
CONTRACTOR CO.il;IP.N0,
ADDRESS ! 17,g`5am Co.
JOB N0. -
a .y ER LY AV. —
CITY 5933
I� iis' Lp10.firsfir / TRUNK PERMIT NO.
e►��S� �Tv6eitil. e II 66 /�li'�
REGISTRATION NO. / TATE
J ] f- tJ COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT N0. STATE ENCROACHMENT� PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT �— 1°N0.OF BLDGS.
NOW ON LOT CHARGES
USE OF t
BUILDINGS CONNECTION CHARGE FEE
NO.1 DESCRIPTI N OF WOR FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLICSEWER @ $ 3.50 —'�•� RECEIPT NO. ( DATE 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 BY
__SEWER OR DISPOSAL SYSTEM 1.00 _
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 I CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR GRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL -
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ I CURB P.L. M.L.TO P.L.
AUTHORIZATION I TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HERE NAMEO
CONTRACTOR TO CONNECT THE ASO.E DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS._........_--------DAY OF . /ff l�` � t I9..._... NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS ��A'`CEN .__.. _._.�._,_..y_.. ....... .. .. .._.._-._.. .. ..___:.�_ BUILDING OR WORK
ADDRESS.J.:�_ _i_... ....° ''ti_.____.._ _.. . SEPTIC TANK,SEEP.PIT(S)
¢- ,�4�----•----• AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT i HAVE READ THIS AAPAI- CESSPOOL E] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR I
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 7
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL N-'
ER OF THE AB E DES kkBESIDENTIA},,.pFIQI; BACKFILL SEPTIC TANKS
3 "
SIGNATURE <' i
4' ° � SEEP.PIT(S}� CESSPOOLS[] s
Ia
OF PERMITTEE_.. �.
,6A642A 663 T/53