HomeMy Public PortalAbout4518 FIESTA AVE_Sewer__ 24650 INSERTS MPLE CITY
76A842D� � � COUNTY OF APPLCATI®N FOR
ANGELESLOS SEWER-SEWAGE MIT
®ISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDIBUMDING AND SAFETY DIVISION ADDRESS 1 Fiesta A
WI I�AM�A I�ENSEN Supt
County
o guddmg LOCALITY Tem le Cit
NEAREST
FOR APPLICANT TO FILL IN CROSS ST r Azusa
LEGAL
DESCRIPTION LOT NO�f.'✓d ` J�carr S .' ' 7 i /r/ OWNER Bill Burge
BLOCK TRACT / 67 MAIL
ADDRESSHondo Pky.
NO OF
/t
SIZE OF LOT NOW ON LOTS 1 CITY E1 Monte TEL NO GI 3-5164
USE OF
BUILDINGS Res. DISTRICT NOO/ GROUP BK MAP P PRRJOCESS PY
CONTRACTOR Square Deal Sew S V U r 6
r
ADDRESS aX«gOn CONNECTION DATA
CITE{1 Monte TEL NO GI w2020 TION 17
DEPTH
STATE MANHOLE REFERENCE nn
REGISTRATION NO 128870 COUNTY OCA • LOWER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
1 PUBLIC SEWER @ $3 00 O TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR Y CURB P L M L TO P L
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO Q
WORK TO HOUSE SEWER @ $1 00 [ V .
SEWER OTER R DISPOSAL SYSTEM OR ABANDON HOUSE @ $1 00 STATE ENCROACHMENT P7
PERMIT NO 0
INDUSTRIAL U
WASTE APPROVAL W
CHARGES ' vi
OWNER S PERMIT $ 2 00 CONNECTION CHARGE FEES 4
AUTHORIZATION TOTAL FEE OO REIMBURSEMENT FEE V
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS 'DATE` INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER All t 71691 1�� 1 -1141,OWNER OR �
OWNERS AGENT *YAW CONNECT ADDITIONAL 1 f
BUILD]NGOR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
LDESCRIBED
COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
AND SEWERS SEWAGE DISPOSAL SYSTEM
Y CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
IA OR THAT I AM THE LEGAL OWNER F THE ABOVE
RESIDNTJAL PROPERTY BACK ILL SEPTIC TANKSE j�� SEE IT(S) ❑ CESSPOOLSITTE G
®" LIDATION ROBERT A WO D
6t 0 CASH SUPERVISING MECHANICAL ENGINEER
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24650 INSERTS npLE CITY
CE2 6D
78AU4A842D � APPLICATION, FOR PERMIT A
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL , 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION TNEAREST
Y i
JOHN A LAMBIE County Eag�neer
WILLIAM A JENSEN Sup t of Building
I
FOR APPLICANT TO FILL IN��jj
LEGAL
DESCRIPTION LOT NO i� C 0�-C 0 ` AAC OWNER Bi11 Bur e
BLOCK TRACT g �J MAIL
ADDRESS
11927 R3.o Hondo Pkyg-
NO OF BLDGS
SIZE OF LOT NOW ON LOT 1 CITY TEL NO
USE OF
DI DISTRICT NO GROUP MAP PROCESS BY r
BUILDINGS Ree BK PG
CONTRACTORSquare Deal Sewer Service �Q� I / I
ADDREsS2933 Maxs on Rd. CONNECTION IATA
CITY onteTEL NO ION DEPTH
REGISTRATION NO 128870 B COUNTY STATE
MANHOLE REFERENCE LO
NO I DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TYPE OF CONNECTION LENGTH FROM /
SEPTIC TANK SEEPAGE PIT OR Y CURB P L M L TO P L
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG ORp'
WORK TO HOUSE SEWER @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO p
U
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT pq
SEWER OR DISPOSAL SYSTEM @ $100 PERMIT NO O
1 Saddle 25 0 INDUSTRIALi
WASTE APPROVAL
P.
CHARGES N
OWNER S PERMIT $ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 1 25 00 REIMBURSEMENT FEE ~
CON
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTINGDATE A CONTRACT WITH THE HEREINpMED DWELLIING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT AT'GN BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL El DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM ~
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER F THE ABOVE
DESCRIBED RESIDENTIAL PROPER BACKFILL SEPTIC TANKS Cl
SIGNATURE 1� SEE ITIS) C] CESSP00 S ❑
OF PERMITTE /
®FALIDATION ROBERT A WOOD
CS to 0 CASH SUPERVISING MECHANICAL ENGINEER _
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