HomeMy Public PortalAbout8720-22 HERMOSA DR_Sewer__ CEBQB 3.✓L er}APPLICATION FOR PERMIT pQ
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL _
DEPARTMENT OF COUNTY ENGINEER �/
BUILDING AND SAFETY DIVISION BUILDING o? —f/Ph YYIA Q..
JOHN A. LAMBIE, COUNTY ENGINEER AODRESs
COLEMAN W. JENKINS, SUPT. OF BUILDING
LOCALITY /t �LjQ L'��P
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FOR APPLIC�rA.NT TO FILL( IN .055 ST.
LEGAL y O O I/ _ V V, kk.4MAIL Ph �P� r
D ESCPIPTION LOT NO. t+ �J OWNER I. p
BLOCK TRACT 3W 43 ADDRESS S / 2 /C �(� �/
NO. OF BLOGS. �'� / q/S/
SIZE OF LOT NOW ON LOT CITY �r L„C TEL. NO. (p O o
USE OF �y �y p DISTRIOTNO. GROVP MAP PR Ep-BY
BUILDINGS G� 1
PIG
CONTRACTOR I � �—!/ Ui
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ADDRESS CO ECTION D A �)
CITY n l�. TTEL. NO! 2 STATION V H� Df PTH 126-1
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LICENSE NO., 7 TATE CLa55 ^ / MANHOLE REFERENCE
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NO. .DESCRIPTION F WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB F.L. M.L.TO P.L.
PUBLIC SEWER SS.00 NO, O
SEPTIC TANK,SEEPAGE PIT OR
PITS ANO/OR ORAINFIELD @ SIO.00 CO-I.P. NO. OB NO v
HOUSE SEWER CONNECTING TO
TRUNK PERMIT ROAD P RM IT NO. Rr
PRIVATE DISPOS AL SY STEM @ S3.00 O
CONN ECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER A INSTR.NO. DATE F
WORK TO HOUSE SEWER @ S3.00 v
OVERFLOW SEEPAGE PIT.DRAINFIELD W
E%TN..CESSPOOL,ORTW ELL,MANHOLE @ E500
A LT ER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING N
/ SEWER OR DISPOSAL SYST�@ 53.00 STATE ENCROACHMENT z
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT CHARGES
s z o0
AUTHORIZATION TOTAL FEE OD CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CO.- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER // APPROVALS DATE INSPECTOR5 SIGNATURE
SIGNED THIS DAY Of- 196�r
OWNERS ,/( 1��-3 ro NEW HOUSE SEWER
OWNER$AGENT "'A_`� � `—
CONNECT gDDIT10NAL
ADDRESS
S 261 PAM- C r/ u BUILDING OR WORK
SEPTIC TANK.SEEP.PIT(S).
HEPEBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION ANO/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER, REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CAL IFOPNIA OR THAT I A HE LEGAL OWN OF, q1 O INTENp TO DISCONNECT PLUG ANO
RESIDE IN. THE ABOV CR IDE IAL p pE RTT. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMTTTE SEEP.PITIS) ❑ CESSPOOLS ❑
VALIDATION JACK R. ALLEN
cK m.G. CASH SUPERVISING MECHANICAL ENGINEER
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