HomeMy Public PortalAbout8850 HERMOSA DR_Sewer__ J6A6A4D J
CE BUBIRE°.°""'
t1 APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
BUILDING 8K PG
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP MAP PROCESSED BY
ADDRESS
CONNECTION DATA
LOCALITY
NEAREST STATION DEPTH
CROSS ST.
UPPER
MANHOLE REFERENCE LOWER
OWNER
.._ TYPE OF CONNECTIONLENGTH FROM
MAIL V. CURB P.L M.L.TO PL
-
ADDRESS
NO.
JO
CO.IMP.NO. JOB NO.
CITY TEL.NO.
LEGAL TRUNK PERMIT NO. ROADPERMITNO..
DESCRIPTION LOT NO.
AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT
NO.OF ELOISE.
SIZE OF LOT NOW ON LOT - HWY.OR ST.WIDENING
USE OF
BUILDINGS - STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
CONTRACTOR— WASTE APPROVAL
ADDRESS _ CHARGES
CITY - TEL NO. - CONNECTION CHARGE FEE 6
STATE '" LIC REIMBURSEMENT FEE u
LICENSE NO. CLASS
NO, DE CRIPTION OF WORK FEE APPROVALS DATE INSPECTO'R'S SIGNATURE
HOUSE SEWER CONNECTINGTO IL
PUBLIC SEWER
NEW HOUSE SEWER Y
PEPTIC TANK.SEEPAGE PIT OR DC
PITS AND/OR DRAINFIELD CONNING ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM O
CONNECT ADDITIONAL BLDG.OR SEPTIC TANK.SEEP.PRISI
ANO/OR GRAINFIELD
WORK TO HOUSE SEWER .I
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL ❑ ERYWELL❑ W
EXTN_CESSPOOL,DRYWELL MANHOLE 10—
ALTER.
ALTER.REPAIR OR ABANDON HOUSE ALTER.'REPAIR.SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSESEWER
BACKFILL BE
PfIC TANKb❑
SEEP,PIT(SI❑ CESSPOOLS❑
OWNER'S Permit s
l I
AUTHORIZATION TOTAL FEE VALIDATION
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
HAVE
TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TOTHE PUBLIC SEWER.
SIGNED THIS DAV OF19_
OWNER
OWNERS AGENT (_ F,
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR r
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF.AND INTEND TO RE-
SIDE IN,THE ABOVE DESCRIBED RESIDENTIAL PROPERTY.
SIGNATURE
OFOE"