Loading...
HomeMy WebLinkAbout1066A (5) , _ � „» � ,� .; ,. ,, �� ; ,. � � � � �bA64�D � ��" �yy�-� ,CE 8081REV b�l�Bj 1/Y9" �(�'f�������J�"A'i�V�'�/�»....`l\+("(j��� +: " ^"�, ,....- v�5 �I.�r t�1�� r��� �V� .. z si�irt�°� - $��i�r���r��o�d��_.w..: ... _�... COUNs'�'Y Of L�$ANGEC�S BUItDING AND SAFETY .. . . ..w,_ � �. _ . , .�.....��...0 ��"OR A/'TLICAI�T TO FILL IN � �� PISTRICT�ND. GROVP MAP-. . � PIVOCESSEO BV BVIL�iNG'� �' �. A +J� �� n) ADDRESS�� J V� CONNECTIOTJ Dr47A LOCALRY 'a� J NEAREST - � ��� ' STATION'- '- i y �OEPTH �.� CRO55 57 a ��.�.. 1 .. , . .MANNOLE'�REFET2ENLE-•.�._..•,.�•��� /�. t1PPER OWNER �• W �''" �TVPEOF�CONIVECTION ... . ..^.'.,.'::,-'-.' MAIL LENGTH�F170M` A�6RE55� Y� �CUR6 P.L.- M.LTOP.L. / /^n�! :-:. � . ..,J. . . . . � .�P.C.NO. ✓�(✓`.. r-J � CO.IMP.�NO. `.. . .. �JOB NO... GITY �TEL NO.�' � L AL .. ... �. . . TRUNK�PERMITNO.. ... . "ROAO'PERiAfTNO ... '....�...,...-." DESCRIPTION�- �OT ND'.� � . - � �� -� AFFIDAYIT WAIYER�EqSFM NT RECORD.INSTR.NO. OATE BLOGK TRACT � ' � � 'NCI.�OF B DGS. � � 512EOFLOT � NOGf6N'C6i'.`.." ....'.' " .'..:. HWY:ORST.'WItiENING".... ' .::"' ........ ...'-.... USEOF 6VIL�INGS ���� ��� STATEENCRORCHMENT' � �������"� �"����"�� � '�����""��'� PERMIT�NO.� ��-� �- � � CONTRACTOR INDUSTRfAL- - � �" � - - ' WASTEAPPftOVAL �AODRE55� J e / GHARGES � R Q� � LONNECTIONCFARGEFEE " � � - -'�"-' '-�'-�- � CITY TEL.NO ' � � STATE' '-"�,i- , �� ���-LIC: ��-// - �" REIMBVRSEMENTFEE �'- � '� ' � LIGENSENO. C�.A55 (,� '- Ho. DESCRIP7lOMOF WORK ._�"FeE ' - � 6d APPROVALS o T GNATURE - HOUSESEWERCONNECTIIVSYO � � � ..... ,. PUBLICSEWER - ' NEW HOUSE SEWER . 5EPT�G TANK;SEEpAGE�PIT Ok � OITS qND/OR DRAINFIELp . GONNECT ADDITIONAL� � � HOUSESEWERCDNNEGTIN6T0 '- �HUILDING'ORWORK '�' � �PRIVATEDf5p05 LSYSTEM� SEPTICTANKSEEP,PITIS)� '�' � � � � � WORKTOTHOUSEISEM�RLY5Y'atlK" "'�""'"�'"' � ._.,._ AND/OR DRAINFSELD � ' O'�ERFLOW SEEPAGEPIT,DRAINF ELD�'-� � C655PODl��❑ DRYWELL❑� � EMN CESSPOOLORYWELC,MANHO�E�' � AI,TER:kEpAIR"OR�(9AIVDONM605E """'� ' - ' � - � SEWERORDISPOSAL`SYSTEM A�TER,REPAIR.SEWEROR ' SEWAGEDISPOSALSY5TEM" ' - DISGONNEGT PLUG AND � � � A6AN�ONHOUSESEVJER� � �- 6ACKFI�LSEPTIC�TANKS G�� OWNER'S �Permlt - . . $ " SEEP,PITIS)Q CESSPOOLS"�] AUTFiOR[ZAtIGN TQTAL FEE � VALIDATION L I HqVE AT THIS DATE A GONTFiACTWRH TFIE��H�IiEIN'(JNAAtEO`CCS'(J-' � ��� ^� " �� TRAGTOR 70 GONNECT THE P.BO\?E OESCk`(QEb EXI571NG tiWELLINGA � - � TOTHE PVBLIC SE.'W7E �a�{,g TN,�� e,.��.0 . . S�GNEDTHIS' G� DAVOF'_ � 19�+-'^ q o OWNEP OR . ]d��s��i�U O_V OWNERSAGEN? ` {� /� �ADDRE9S �-...� 1(S C R l..C}'�}a.J L.. . .� .. I NEREBY AtKNOWLEDGE TF7AT I HAVE'REACS'7H7S"APPCICAI'fC1V" ( q O ANO STATE THpT THE ABOVE IS'COqRECT HN�AGkE'E'YO COMpLY" . :jj.(h 9 9`��%O � WAH�ALL CDUNTY OROINKNCE$ AND 3'(ATE'CkW5,�'R'Ek:411MYJG" � PL(lMBINGAN�SEWERS: � � 1 -�1�'HEREBY CEYi71FY""FHAT f"AK.'"pTiOPEkiL�Y�REp 15'f'!`kE$°AND/UYi"` - LICENSED A6 REOUIfiE�BV LpSANGEL"ES'40UNtV"AN15 57ATE(5F'" CALIFORNfA OR TfiAT I'AMTHE l'ECadl:'OY4NEIY'OF:XNU 11VYE'NISl"L Y£E--� SIiSE"M�.TFE%RB04E'DESCRfBEa`R�SIDEF77V �PR`OPEkT,�. � � � '�: S . � . � . . . SIGNATURE OFPERI.YI'I''YEE':-_ . ___ ��������a�€t����� ,.... � . : � �������€����o������asa. . � � _ �. -� � � � l.INDICATE At! BJiLDiNGS ON"PROPERTY, 2.INDICATE AND DIiVIEl�S;ON SEWAGE �15POSAL SYSTEl� WIIH`��T1E`�ISTANCES.'TO BIJILDI,NGS � � � � ` � AND PRGI'��TY LIN�S. ' ,. , . . �. 3.INDiCATE SIZE OF SEPT(G TANK-dEP7H,QF SEEP- " � ; AGE PITISI•SIZE OF CESSPOOLIS).' � ; 4.lNDICATE NQf�TH DlRECfION ON FLGT. ���D� - � �y'`` ' u � � �� _ �, � '� 3�; � , _ 5.iNDlCATE 60TN STREEF5IF CORNER, " „ , _ _ � . : ,..., � � � ; __ ,,�_��..•5`I`:`dL��EY R�17U...:��, FIELD NOTESM . ;-,�, ,.___,. .... �� ��� r�� �._> � ����'`��ti � � y.., :.,s F.� �''�= �� , �.: ,� , ,� r� J _ ;;;--