HomeMy Public PortalAbout8615 HERMOSA DR_Sewer__ 24650 INSERTS
Q`°° °° APPLICATION. FOR PERMIT
TspsaxD COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSIONBUILDING
'
WT
A. LAMEIE, 0°uEngineer ADDRESS
WILLIAM A. JENBEN, Suptp't of Building LOCALITY
NEAREST
FOR APPLICANT TOO FILL IN CROSS ST.LEAL
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DESCRIPTION LOT NO. D Jy 5 / OWNERMAIL
BLOCK TRACT
J / � ..1 ADDRESS ATS"'
�' ./ N0.OF BLDGS. "y //
SIZE OF LOTS 6' X a O NOW ON LOT 4... CI �� TEL. N0. 10^ Va
USE OF , DISTRICT N0. GROUP I MAP PROCESSED B°Y /
BUILDINGS �P-eac.. �/
� BK PG
CONTRACTOR .�
ADDRESS CONNECTION DATA
CITY TEL.NO. STATION ('-m5-,7. DEPTH '
STATE MANHOLE REFERENCE p ` UPPER
REGISTRATION NO. ❑ COUNTY / a Y/L L ER"
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO -
PUBLIC SEWER @ 83.00 TYPE OF CONNECTION LENGTH FROMSEPTIC TANK.
-
PITS AND/OR DRAINFIELDIT OR @ $3.00 Y. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EKTN..CESSPOOL.DRYWELL @ S2.00
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. O
WORK TO HOUSE SEWER @ $1.00 O
ALTER.R"'cram-QR-:.BAN6BfV HOUSE �--(� STATE ENCROACHMENT pa
SEWER ORv'e�iv^'�:..:=mT-'c�i @ 51.00 PERMIT NO. O
INDUSTRIAL U
WASTE APPROVAL W
P
CHARGES a
OWNER'S PERMIT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE JgO_Z�$ REIMBURSEMEN T FEE
I HAVE DATE ACON-
TRACTORA TO CIONNECT THE ABO ET DESCRIBED EXISTINGTHE HEREINAMED DWELLIING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL --
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER.REPAIR,SEWER OR
PLUMBING AND SEWERS, SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF pBAN DON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENWL PROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE ' n /} SEEP.PIT(S) El CESSPOOLS ElOF PERMITTEE `�,� 1�.i
®" VALIDATION ROBERT A. WOOD
CIL M.o. °ASH" SUPERVISING MECHANICAL ENGINEER
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