HomeMy Public PortalAbout8708 HERMOSA DR_Sewer__ 76A 6420 -CE808-10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FA
ING E/1�
SS /
ITY
ST
FOR APPLICANT TO FILL IN ST.
LEGAL 5
DESCRIPTION LOT J R
m l , f�•�BLOCK TRPCT ✓ f� y 1 SS
NO. OF BLDGS.
SIZE OF LOT 117 NOW ON LOT CI TEL. NO.
USE OF
BDII NG DISTRICT NO. GROU BK Pi MAP PROCESSED BY
LO
CONTRACTOR ' J✓f�
ADDR A CONNECTION DATA
STATION A DEPTH I'
LICENSE NO. CLA35 MANHOLEREFERENCE I W WBR'
No. DESCRIPTION OF WORK FEE TY P E OF CONNECTION LENGTHFROM
HOUSE SEWERCONNECTINGTO A-Y/l.. Y. CURB P.L. M1.TO P.L.
PUBLIC SEWER 0 $7.00 V'�
SEPTIC LANK.SEEPAGE PIT OR P.C.NO.
PITS ANO/OR DRAINFIELO 510.00 CO. IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO L
PRIVATE DISPOSAL SYSTEM 0 S3.00 LY O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT •IY,I. EASEMART RECORD.INSTR,NO. DATE U
WORK TO HOUSE SEWER 0 53.00
OVERFLOW SEEPAGE PIT.GRAINFIELDOC
E XTN..CESSPOOL.ORYW ELL. IIS 00
HWy,OR GT.WIDENING O
ALTER. REPAIR OR ABANDON HOUSE (—
SEWER OR DISPOSAL SYSTEM @ $3,00 STATE ENCROACHMENT W
MANHOLE 0 $7.00 PERMIT NO, OL
INDUSTRIAL N
WASTE APPROVAL Z
OVVNER'S PERMIT E s 00, CHARGES
AUTHOPUATION1 TOTAL FEE € CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTORS SIGNATURE
SIGNED THIS DAY OF 19_OWNER NEW EWER
A
OWNERS AGENT CONNECTECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANKL
SEEP.PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. L ❑ DRYWELL ❑
I HEREBY CERTIF THAT I AM .PROPERLY REGISTERED AND/OREPAIR.SEWER OR
CA"FOED AS RE IR BY L LES CO rvTY AND STATE OF DISPOSAL SYSTEM
CALIFORN Iq OR A AM T E LEGA OWN OF
AND INTEND TOECT PLUG AND
RESIDE IN. T BOE RIBS SID T PROPERTY. N HOUSE SEWER
SIGNATUR OF PE RTE L SEPTIC TANKS
IBI ❑ CESSPOOLS ❑
VALIDATION CK. M.D. A3H
v 8�7
i.A,Co 0 8 8 6.3 FB 2 1 0 A 1 0.00-
76A 6420 -CE808- ID-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING O
ADDRESS
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN ROSS ST_
LEGAL {,
DESCRIPTION LOT NO. 1/(SM1 OWNER _
ryry MAIL
BLOCK TRACT r I.It -�V / ? ADDRESS
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT TEL. NO. ,
USE OF
BUILDINGS DISTRICTNO. GROUP I
BI( MAP PS PROCESSED BY
CONTRACTOR
ADDR CONNECTION DATA
• NO v STATION ✓`�_ �/ DEPTH f 1.�
STATE LI= ' f' I —MANHOLE REFERENCE +? ['S G 17 LO-uMW R
LICENSE NO. CLA 55 If I
NO. DESCRIPTION OF W RK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER ® $7.00
SEPTIC [ANK.SEEPAGE PIT OR P.C.NO,
PITS AND/OR GRAINFIELD @ 510,00 CO. IMP. NO. JOB NO,
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT 14 y
PRIVATE DISPOSAL SYSTEM ® S3.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wArvu As[x[ RECORD.INSTR.NO. DAT v
WORK TO HOUSE SEWER ® 53.00
OVERFLOW SEEPAGE PIT.DRAINFIELD d/
EXTN,.CESSPOOL.DRYWELL. ® S5.00 O
ALTER. REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING F
SEWER OR DISPOSALSYSTEM S3.00STATE ENCROACHMENT U
MANHO E PERMIT NO. OC
® $].00 N
WASTEINDUSAIAL
WASTE APPROVAL Z_ .
OWNERS PERMIT CHARGES
AUTHORIZATION I TOTAL FEE 3O CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
1 HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLIj
SEPTIC TANK.SEEP.PIT(S)
AND STATE THAT THE ABOVE IS CORRECT ANO AGREE TO AND/OR DRAINFIELD
WITH ALL COUNTY ORO ANCES AND STATE LAWS REGUPLUMBING AND SEWERS CESSPOOL ❑ ORYWELL
I HEREBY CERTIFY A� I AM PROPERLY REGISTERED ALTER.REPAIR.SEWER OR
LICENSED AS REOU O L05 ANGLE$ COUNTY AND STS EWAGE O ISP.SAL SYSTEM
CALIFORNIA OR T A THE LEGA WNER OF. ANO INTDISCONNECT PLUG AND
RESIDEINGRIBED RE51 ENT A PROPERTY. ABANDON HOOSE SEWER
SIGNATURE BACKFIL
ITL ISEPTS) ❑IC TACESSNK$POOL❑
OF pER TEE S ❑
SEEP.P
VALIDATION CK. M.D. CASH
IIS( c 8 8 /,� r=a 2 1 1 A 3 O.L�� 7