HomeMy Public PortalAbout9119 WOOLLEY ST_Sewer__ APPLICATION® �rye(� pq.(
6&E- S APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER--SEWAGE DISPOSAL
Department of County Engineer
County of Loa Angeles BUILDI
WM. J. FOX, COUNTY ENGINEER ADDRESS
CASSATT D.GRIF'F'IN; SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST-
CROSS ST,
LEGAL o
DESCRIPTION LOT NO. OWNER +,
BLOCK TRACT MAIL
RE.S t _
N0.OF BLD S. �F_�--
SIZE OF LOT NOW O LO '+ I. a T
USE OF .�.'
DIST GROUP i MAP
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CONTRACTOR
ADDRESS '+ ° ",da 'I CONNECTION DATA
CITY r` TEL. N0.< " ^ STATION DEPTH 5
_ a STATE-- ,~ � MANHOLE REFERENCE
REGISTRATION NO. I.._4 COUNTY
.. j.: TYPE OF CONNECTION -. LENGTH FROM -_...
N0. DESORIPTION OF WORK FEE Y. CURB _P.L. M.L,TO P.LL,
IIOLSr S WLR CONNECTING TO —
PURL Ca ttiER_ Q $ 3.50 I --- —
��
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM__CONNECT 70 A USE SEWER
BLDG. OR ! ?
�I � CO. SMP.NO JOB. N0.
WORt_T_0 HOUSESE4"ER_ 1..06 -
'� ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM_ _ 1.00 ( TRUNK PERMIT NO, ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER � �— STATE ENCROACHMENT —
AND/OR DISPOSAL SYSTL-M -1__00_, PERMIT NO.
Tj SEPTIC TANK SEEPAGE PIT OR
i PITS AND/OR DAA NFI_ELD 2.00 I INDUSTRIAL
I CESSPOOL DRYWELL WASTE APPROVAL
I SPECIAL CONDITIONS ONLY 2.00 I CHARGES
OARS W PERMIT - I o
CONNECTION CHARGE FEE -
$ I
1
AUTHORIZATION TOTAL FEE '� REIMBURSEMENT FEE
HAVE THIS DATE CONTRACTED WITH HE HEREIN. NAMED CON-
I
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER `—'---` —`--
NEW HOUSE SEWER
SIGNED THIS—. DAY Or ---
,,
OWNER OR CONNECT ADDITIONAL
�, tT+ .eSt� -.f,*'
OLYN GcR _ Ff BUILCING OR WORK _ —
ADDRFi -- .-- �l !r _- —.�.__ SEPTIC TANK SEEP,PIT(S)
_AND/OR CRAINF}ELU
I HEREBY ACKNOWLEDGE THAT 1 HAVE. REA�K `tHiS APPLICATION C€55POOL[] DRYYYELL 0
AND STATE THAT THE ABOVE IS CORRECT AN AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STA LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I t-:ERE?Y CERTIFY THAT I A7r1 PROPER Y REGISTERED a,,ND!OP, DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOPLU AND
CALIFORNIA OR THAT t AM THE LEGAL OWNER OF THE ABOVE _ .w ___
D"SCRIBED RE.SID€NTIr,AL PROPERTY. BACKFILL SEPTIC TANKS❑
SEEP. PIT($) cl CESSPOOLS
SIGNATURF.
OF PERMITTEE_
_.__.a_v...
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
,
6Y BY _
DEPUTY DEPUTY
BY - BY
(VI DEPUTY DEPUTY