HomeMy Public PortalAbout8804 HERMOSA DR_Sewer__ )bAbE9D
CE BDB(REV.61781 AP�LfCON FO MIT
O,
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFET
FOR APPLICANT TO FILL IN msrRlcr No. - -GROUP MAP I PROc ED BY.
BK PG
BURILDING D� /,;4v-4
ADDESS
CONNECTION DAT
LOCALITY
NEAREST STATION DEPTH
CROSS ST.
UPPER
MANHOLEREFERENCE LOWER
OWNER TYPE OF CONNECTION LENGTH FROM
MAILY. CURB P.L. M.L.TO P.L.
71
ADDRESS
JT- TEL.NO. OZra3— /O 9{!J P.0.N0.
CITY GOIMP.NO. JOB NO.
LEGAL TRUNK PERMIT NO. ROAD PERM IT NO.
DESCRIPTION LOT NO. Zz
Q� AFFIDAVIT I WPIVEfl I EASEMENT RECORD.INSTR.NO. GATE
BLOCKTRACT
NO,OF BLDGS. �f
512E OF LOT;�5y 1"X1161
NOW ON LOT v HWY.OR ST.WIDENING
U5E OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
CONTR INDUSTRIAL '
Q WASTE APPROVAL
ADDRESS CD3 CHARGES
-' •TEL.NO. 3a 2/ CONNECTION CHARGE FEE
C d
STATE / LIC. EIMBV RSEMENT FEE
LICENSE NO. [Q GLP.55 — O
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'5 SIGNATURE V
HOUSE SEWER CONNECTING TO a
'PUBLIC SEWER
SEPTIC TANK.SEEPAGE PIT OR NEWHOUSESEWER
PITS AND/OR GRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG.OR SEPTIC TANK.SEEP,PITS)
1 WORK TO HOUSE SEWER ANO/OR GRAINFIELD
OVERFLOW SEEPAGE PIT.ORAINFIELO CESSPOOL [I DFYW ELL❑
E% N..CESSPOOL.D RYWELL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE ALTER.REPAIR,SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND"' -- -
ABANDONHOUSESEWER
BACKFILL SEPTIC TANKS El _
OWNER'S �y
Permit g SEEP.PITS) CESSPOOLS
AUTHORIZATION TOTAL'FEE ' ' ALIDAT
I HAVE AT THIS DATE,A,CONTRACT,WITH THE.H EREIN NAMEWD COp O
TRACTOR TO CONNECT THE ABOVE ESCRIB ED EXISTING DELLINN- '/K 0,0 0 0 1
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 1 Q 0 . 1 (L Q O
OWNEROR
OWNERS AGENT • 4
_ 0 p.p 1 •oO U..
ADDRESS T1 4.28-.-80
, �]Op p
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION - -O 4•G 'v Q
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORO ANCES AND STATE LAWS REGULATING
PLUMBING AND SEWER -
HEREBY CERTIFY AT I AM PROPERLY REGISTERED PND/OR
LICENSED AS REOUI BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR TM AM THE LEGAE. WNER OF.AND INTEND TO RE- _
SIDE IN,T FAM THE
REST ENTIALP PERTY.
SIGNAT R -OF PE MITTE