HomeMy Public PortalAbout8828 HERMOSA DR_Sewer__ 24650 INSERTS
CE9086-90 APPLICATION FOR PERMIT
TCAeazD COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
g ADDRESS
Wineor
ILLIAM A. IENSEN. SuP t o!Bwldiu4 LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGALn
DESCRIPTION LOT N0.f, 1.(Yq X L I Q OWNER
BLOCK TRACT ^� MAIL
ADDRESS
N0.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY .,-t EL. NO.
USE
BUILDINGS
STATE DISTRICT NO. GR UP MAP A
FIRPROCESSED9KruCONTRACTOR
ADDRESS CONNECTION DATA
TEL.NO. STATION DEPTH
•CI7Y `
MANHOLE REFERENCE
REGISTRATIO
LOWER
NO. j DESCRIPTION OF WORK FEE
HOUSE SEWER
CONNECTING TO
PUBLIC R @ $3.00
TYPE OF TION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P,L. M.L.TO P.L. --5
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN..CESSPOOL. DRYWELL @ $2.00 O p,C.NO.
HOUSE SEWER CONNECTING TO CO. IMP. NO. /3� JOB N O
PRIVATE OI SPOSAL SYSTEM @ $1.00
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. p
WORK TO HOUSE SEWER @ 81.00 U
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO. p
INDUSTRIAL U
WASTE APPROVAL WM
CHARGES
OWNER'S PERMIT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE Fr10 O REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SE ER.
SIGNED THIS DA OF 19 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE PEND THIS APPL CATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ ORYWELL ❑ -
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
PLUMBING SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROP RLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED Y LOS ANGEL S RUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR TH AM TN
LEG L WNER OF THE ABOVE
DESCRIBED RESIOEN ROPER BACKFILL SEPTIC TANKS El
SIGNATURE SEEP.PIT(S) 0 CESSPOOLS �6 V L+4LfA
OF PERMITTE
®" VALIDATION ROBERT A. WOOD
GK Y.o. CASH SUPERVISING MECHANICAL ENGINEER
5 .-