HomeMy Public PortalAbout8721 HERMOSA DR_Sewer__ 6ID-63
A64 APPLICATION FOR PERMIT
C E808 D
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONBU ILGIrvG
JOHN A. LAMBIE, County Engineer ADDREss ✓H.�a�(.Q�
WILLIAM A. JENSEN, Supt of Building X
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS GT.
LEGAL ✓ nn
DESCRIPTION LOT NO. OWNEftV
�� 13 MAIL
BLOCK TRACT �/ ADDRESS
NO. OF BL GS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROU MAP PROCESSED BY
BUI LDINGB
BKED
CONTRACTOR
ADDRESS /p'� d f.f T CONNECTION DATA
7j / STATION DEPTH
CITY TEL- NO. L7
��(( // E MANHOLE REFERENCE UPPER
REGISTRATION NO. V� T V COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. }
PUBLIC SEW ER n8 55,00
SEPTIC TANK,SEEPAGE PIT Oq P.C.NO. d
PITS ANO/OR ORAINFIELD 810,00 CO.IMP, NO. JOB NO. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM AD 53.00 W
CONNECT ADDITIONAL M AFFIDAVIT wp1V[N [AS[K[Nr RECORD.INBTR.NO. DATE O
WO RK TO HOUSE SEWER $3.00 I! V
•` OVERFLOW SEEPAGE PIT,GRAINFIELD W
E%TN.,CEESPOOL.DRYWELL.MANHOLE @ ".Do a
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING N
SEWER OR DISPOSAL SYSTEM 53.00 STATE ENCROACHMENT z
PERMIT NO.
INDUSTRIAL l /
WASTE APPROVAL
CHARGES
OWNERS PERMIT S z 0
}0.[
AUTHORIZATION1 TOTAL FEE L// 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
TO THE PUBLK SEWER. APPROVALS DATE ..SPE TOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP.PITIS)
1 HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION AND/OR DRAINFIELO
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ONYWELL ❑
IHEREBY 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
CALIFORNIA OR THAT AM THE LEGAL OWN R1OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, TXE' V DE C BbBJ2ESIDE I L PR ERTY. ABANDON HOUSE SEWER
SIGNATURE /l ❑
OF PERMITTEE BACKFILLIT(E) TIC TANKS
BEEP,PIT IST ❑ CESSPOOLS ❑
VALIDATION ROBERT WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
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A09. 1 6 31- JAN 26 1 Q A 5.00-
IN