HomeMy Public PortalAbout9073 WOOLLEY ST_Sewer__ ��BEaaA 9<�ess�.ss APPL ICA1TION FOR (PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angers BUILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS
CA$BATT D.GRIFFIN, SUPT OF BUILoING LOCALITY
7FOR APPLICANT TO FILL IN
NEAREST
,n. CROSS ST
LEGAL
DESCRIPTION_ LOT NC. _ � OWNER
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MAIL
_BLOCK nACT `e �"�: i°f` ADDRESS
NO. OF BLDGS, ----_.�---
SIZE OF LOT NOUN ON LGT ,,-�. _ CITY TET.. NO.
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BUSE LODF
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CONTRACTOR ,,�/' ✓y�. 1
ADDRESS CONNECTION DATA
CITY - --- _T,17LNO. STATION. d� 4 DEPTH
STATE MANHOLE REFERENCE ,rUPPER 4
REGISTRATION NO. [C3 COUNTY
No. DESCRIPTION GE WORK--- FEE
---� HOUSE EWER CONN eCTING TO �y Vis•^"" TYPE OF CONNECT DN LENGTri FROM ,
t r_PUBLIC SEWER_ ___ @ $ 3.50 1�'--- L.TO P L.
j _ _— .._
fj LOUSE £tdCR CO�Sh£CTfNG iJ )}
PRIVATE DISPOSAL SYSTEM 1,00
I CONNECT ADDITIONAL BLDG. OR i ; �€•^ f' r I30.
i WORK TO HOUSE SEWER 100 -CO, iMl?. NO. �}`--- -JOE NO_� --�--i
1
ALTER OR REPAIR EXISTING —�
S tYtR OR DISPOSALS STEM 1,00 TRUNK PERMIT NO. ROAD PERMIT NO,
DIS ONNEC AND ABANDON SEWER
AD'OP DISPOSAL SYSTEM 1.00 STATE ENCROACHMENT
PERMIT NO. _
SEPTIC'TANK, SEEPAGE PIT'OR --�`-- ---"— —"---
P IS AND/.OR DRA114FIELD 2_00 WASTE STIAL APPROVAL
WDRYELL -- - --j -.. -=--
SPECIAL CONDITIONS ONLY
—..--'- ---'------- CONNECTdON CHARGE FEE
OWNER'S PERMIT t 00
AUTHORIZATION � TOTAL FEE � ,� ��, R£IBfBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESC2iBED EXISTING DWELLING APPROVALS
'PROVALS DATE INSPECTOR'S SIGNAT URE.
TO InE PUBLIC SEWER
— _^ _
SIGNED THIS _.—.Drh'i C?T I ....__ NEW HOUSE SCf CR i
OWNER OR CONNECT ADDITIONAL
OWNERS kGCNr BUILD NC OR WORK _
ADDP SEPTIC TANK,SEEP. PIT(S)
AND/OR D.RAINFIELD_
---I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL,[) DRYWELLO -�
AND STATE THAT THE ABOVE 1 COPRECT AND AGREE TO COMPLY _
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING SEWAGALAYTERPLUMP�Nt AND SEWERS. ALTER,REPAIR SEWER OR {
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I HEREBY OWNER CERTIFY THAT I Alf PROPERLY REGISTERED AND/OR --- � —"
LICENSED A� REQUIRED BY Lo
PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OF THE ABOVE ABANDON' NOUS SEWER
S ANGELES COUNTY AND STATE OF DISCO
__. _
DESCRIBED RESIDENTIAL PROPERTY, BACKFILL SEPTIC TANKS C _ -
SEEP. PIT(S) [] CESSPOOLS
_.._
' SIGNATURE .
OF PERMITTEE - Ri
WILLIAM J.FOX.COUNTY ENGINEER VALIDATION R.A.WOOD, CHIEF PL8G. INSPECTOR
°. n DEC 6 4 A.5 ()