HomeMy Public PortalAbout8706 HERMOSA DR_Sewer__ )6A 642D-CEBOB -IO-TI APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY
NEANES
[LONGS
OR APPLICANT TO FILL IN CROSS
ONLOT O.• OWNER
MAIL
TRACT 3o ADDRESS
NO. OF SLOGS.OT �W NOWONLOTCITY TEL. NO.
DISTRICT NO. GROUP MAP pROC SSEO BT
BKPPiOR CONNECTION DATA,/y• O D� STATION 15 DEPTH I '�
STATE ✓L LIC _ 1/ `J J UPPER
LICENSE NO CLAS .I _ MANHOLE REFERENCE �2 �. I A LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION 4 LENGTH FROM
HOUSE SEWER CONNECTING TO `'') \ Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER 0 $7.00 / QV
SEPTIC TANK,SEEPAGE PIT OR P.C.NO-
PIT$ANO/OR GRAINFIELD SIO.00 CO.IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. D-
PRIVATE DISPOSAL SYSTEM 53.00
CONNECT ADDITIONAL SLOG.OR AF=E ..T RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER @ S3.00
OVERFLOW SEEPAGE PIT.GRAINFIELD OC
EXTN..CESSPOOL.DRYWELL. @ $5.00 O
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM $3.00STATE ENCROACHMENT u
W
MANHOLE ® $7.00 PERMIT NO. y
h
INDUSTRIAL Z
WASTE APPROVAL
OWNERS PEHMTT s 3 oD. CHARGES
AUTHORIZATION TOTAL FEE G CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE GE.CNI.ED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER, DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAV OF 19_ {� �
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS
BUILDING OR WORK
EPTIC
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OTGRAINFEL PIT(S)
AND/OR GRAINFIELD
AN STATE THAT THE ABOVE 15 CORRECT AND AGREE E COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYW ELL ❑
I HEREBY CERTI THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED A5 RE Ifl BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR AT AM E L AL OW ER OF, AND INTEND TO
RESIDE IN. T B E OE RISE flE5 NTIAL PROPERTY. DISCONNECT PLUG ANO
BANGOR HOUSE SEWER
SIGNATURE
OF PER IT •� BACKFILLITI.1 TIC TANK5 ❑ 1
SEEP.PITIBI ❑ CESSPOOL ❑I
VAL ATION CK, M / ASH
.A('o0084;� FEB 21 0 A 10.00-I v
76A 6420-CE808 - 10-7I APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADORERS
LOCALITY
NEAOEST
FOR APPLICANT TO FILL IN
S. $T.
EGAL
DESCRIPTION LOT N17 O. OWNER
MAIL
BLOCK TRACT � ADDRESS
/] NO. OF SLOGS.
SIZE OF LOT { Yi NOW ON LOT CIT TEL. NO.
USE OF
BUILDINGS DIS{TTRICTNO. GROUP Mp P/]'�� PROCESSED BY
PC
CONTRACTOR
ADDRESS CONNECTION DATA
CIT STATION '13-+4-3
DEPTH E
LICENSE NOE CLAS MANHOLE REFERENCE 41'2 T I `T\ OWE
N -DESCRIPTION OF WORK FEE - j��f} TY PE OF CONNECTION / LENGTH FROG.
HOUSE SEWER CONNECTING TO Y: CURB P.L. M.L.TO P.L.
PUBLIC SEWER ® $7.00 P.C.NO,
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DR .0
AINFIELD $'00 CO. IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT.0NO. ROAD PERMIT d
PRIVATE DISPOSAL SYSTEM 330 Np� O
CONNECT ADDITIONAL BLDG,OR AFFIDAVIT I WEIIIO 'IASIMURY RECORD. INSTR.NO. DATE V
WORK TO HOUGE SEWER @ 33.00
OVERFLOW SEEPAGE PIT.DRAINFIELD O!
E%TN..CESSPOOL.ORYWELL. ao $5.00 HWY.OR ST.WIDENING O
ALTER,REPAIR OR ABANDON HOUSE V
SEWER OR DISPOSAL SYSTEM 33.00 GTATEENCROACHMENT W
MANH Q $7.00 PERMIT NO.
INDUSTRIAL h
WASTE APPROVAL Z_
CHARGES
OWNERS PERMIT s �—.,e —vo—
AUTHORIZATION TOTAL FEE � CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'5 SIGNATURE
SIGNED THIS DAY OF 19_ 97�
OWNEROR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS
BUILDING OR WORK
SEPTIC TANR,SEEP.PITIS)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS_ CESSPOOL Cl DRYWELL ❑
I HEREBY CERTI T AT I AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR.SEWER OR
IICEN$ED AS R BY OS AN COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA O A AM E L OW E OF. AND INTEND TO DISCONNECT PL D
pESIOE IN. T DE CRIB EGID IAL PROPERTY. ABANDON HOUS SEW R
SIGNATUR BACKFILL SEPTI TANTS ❑
OF PERMITTEE SEE I.PIT(S) CE^� POOLS []
LIDATION
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