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Home My WebLink About1055A �... - _ ... � 76A642� CE806;REV.6i7811;79 /� �� /��r}/""�� Os ��1 !"'i I�u.�J .��ER ' .�"JG��e�7� ��P� `��' �►�., COU(�TY OF��S A6V�ELES BU@l�IIdG Att�D SAFE'fY FOR AP�LI4P4NT�O FI1LL I� � � � � DISTRICTNO. GR UP MAP PROCFSSED BY ADDRESS+�..✓. I(1 � > / � "a�+J 4+ iLc "'�G � / �., � �41e91VECTlON DATA LOCALITV .`, NEAREST STATION ��h DEPTH CROSS 5T. � Z� . � MANHOIE RE�ERENCE �,�� PPER � �l (/(�'7 /�Jd LOWER OWNER 16^�� `^ s TYPE OP C4NNEGTION LENGTH FROM � MA�L Y. CURB .L. M.L.TO P.L. ADDRE55�,�� ^� � P.G.NO. . .+"'�'��++ 4•/�_� C.O IMP NO. Jb6 NO. .:/�,�� o.J CITY � TEL.NO. � d � . LEGAL TRUNKPERMITfVp. ROADPERMITNO. DESCRIPTION LOT NO. �-y ^� AFFIDAVIT N'AIVER EASEMENT RECORD.INSTR.NO. DATE BLOCK TRACT ��U ✓ NO.OF'8LL1G5. � '—' S12E OFLOT NOW ON tOT ' HWY.ORST.WIL?ENING USE OF BUILDWGS STATE ENGROACHMENT PERMIT NO. � INDUS7RIAL _� CONTRACTOR WRSTE APPRQVAL � � - ADDRESS aJ� + , s ,�e � CHARGES CITV TEL NO. ..`�� '� GONNECTIOIV CHF+RC+E FEE a" LICAENSENO.� � CLASS �- �'�,, REIMBURSEMEN7FEE � NO. DESCRIPTION OF WOF2K FEE ,4ppR(y��g DAT I CT ' SIGNATURE � . HOUSE SEWER GONNECTING TO '.91 ��,' PUBLIC SEWER O�� SEPTIG 7ANK,SEEPAGE PIT OR NEW HOUSE>EWER PITS AND/OR DRAINFIELD � CONfdECT ADOIT70NAL t 88�.7 HOUSE S6WERCONNECTING TO BUILDING QR WORK A°�, PRIVA7E DISPOSAL SVSTEM QPd CONMECT ADDITIONAL BLDG.OR SEPTIC TANK.SEEP,PITI51 � �MOR4:T�FtOUSE SEWER ANO/OR DRAINiIELD ,� OVERFLOW 5EEPAGE PIT,pRAINFIELD � CESSP06L C �RYWELL❑ EXTN._GHSSpOOL,DRYWELL.MANHOLE ALTER,REPAIR OR A6ANDON HOUSE � � --� qLTER,REPAtIi.SEWER OR SEWER OR OISPOSAL SVSTEM SEWAGE DISPOSA�SYSTEM - DISCONNEC7 PLUG RNO ABANDON HClUSE SEWER BAGKFILL SEPTIC FANKS(] � PeffYllt � ') 5EEP,AiT15)Q CESSPOOtS❑ QArV9�ER S '�A�C9DATIQ�+B �AU7HOF�1��11�IOiV TOTAL FEE � � �} � ��_� � NAVE AT THIS DATE A GONTRAC7 WITH THE HEREIN NAMED GON- "RACTOR TO CONNECT THE AOOVE DE$CF3IBED�EXISYING DWELLING f0 THE PUBLIC SE� ,��t7 �''ffi � 'e �m � � 51GNEDTHIS DAY F �'" �„_19� � ('�( OWNERSA�ENT �-. a Cl '�� 9 '� R,4,' `^' ' . . ADORE55_ .. . ; . . � `m ,� �4 C� .1��t�s 1 AND STATE THAT T�HE AHDOVE ISAGORRECT ANDDAGREE TOLCOMP�Y �� y ��O1 '' WITH ALL COUN7Y ORDlNANCES AND STA7E LAWS REGULATIIVG PLUMBING AND SEWERS. � � I HEREBY CERT�FY THAT 1 AM PROPERLY REG�STERE� AND/oR LIGENSED AS REqUIRED BV 1.05 AWGELES COUNTY AND STATE OF GALIFORNIA OR THAT 1 AM TIiE LEGAL OWIVER OF,AND INTEfd�TO RE- SIDE IN,THE AB6VE DESG6EIBED'RE5IDENTIAL PRt3PERTY. � ' SIGNATURE �q-��y� �' OF PERMIYTEE L s�'f�.P�� "'^S;'a�n�.� . . . . -.wmm.,amm.xmum�.� .. .. . . . _._,, . . . . .. .. . ... .�e..' '... . .. . . _ .. . �,. �f��.�`��3"�3�� `�� 1. if�1DECATc ALL �,UIL.i�P[�it",.�5 Oh3 �RQPERTY. !-�,_._._� 2. It�ii�lGATE Q4�J� C1,"��EP��i��i S�WF��sE �lSP£�;�Al. , s�sr��t v��r� �� es��:t��s �� au��.a!��s . � A�!!� PR�PE�T� L�i�Es. � '` � �.'�.: Y 4 5;,�y� 'Y'+8 ._�`A..$. . ^.'��R 'Y 'J�t�lq.�,� .1M,v.f'...:F :_ a, e��cd��-� �:�� ra�€��-��-; �� ;��P- �-��`I�'i�{S� �.u•i��'a�i��'��.��i. . ' . ^�. , , ., �.,�..)',..�»s �i;.. . 4. ere��-��t��i��9�,��`�;� ��. a .� b ; �.,: -F ;��..:�-� �._� �: �, ry. _§`; ; ��. �, s. ��r��TL��s;��!��, _ , . . . �� , �. . : � � s., � W. w �. ' . _.. w., 't . ...h'� . a.�..�y. Y,II�.' .. " , , � � .. ..�.a...1•. .,. .J �'�-.� ".,�"t, . . ..., - ✓ y. a . .,i.::.._�.i ., ..Y.,..i . . .w �'ar A. ��'- �. �,..��'." STa�f.LE1`R/`�' FIEI,.�[�J�TE� � � �.�...�..,,,�...._..�. � ........, ,. . ....W'i�« �...8; � :4��. . ..._ . . , . ' . � . �a,. ,�.:..e. .