HomeMy Public PortalAbout8852 HERMOSA DR_Sewer__ 76Pb42D i �
CE8081aE°°"fl' APPLICATION FOR P RMIT
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SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT T FILL IN DISTRICT NO. GROUP MAP PflpcE D ev
BUILD IN
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LocALITr75/'a6'6 CONNECTION DATA
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CROSS ST (J .vL.
MANHOLE REFERENCE y / �j PPER
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OWNER
TYPE OFC TION LENGTH FRO
MAIL Y. CURB PL_
M.L.TO P.L.
ADDRESS
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CITY TEL.NO.ZZ p _ �� CO.IMP.NO. O JOB NO. f
LEGAL TRUNKPERMITNO. ROAD PE RM IT NOl/e-Jr-S'
pESCRIPTION LOT NO.
AFFIDAVIT WMVEN EASEMENT RECORD.INSTR.NO. DATE
52E OF LOT N
BLOCK TRACT
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ON LOT HWV.OF ST.WIDENING
USE OF - 4' OY V �T
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
CONTRACT NDUSTRIAL
WASTE APPROVAL
ADDRESS CHARGES
f _al CONNECTION CHARGE FEE
CITY TEL.NO.
STAT LIC.
LICENSE NO. REIMBURSEMENT FEE
CLASS
NO. OE9_CRufTioN OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE �J
/ HOUSE SEWER CONNECTING TO
PUBLIC SE WER
S EPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWEfl G 77fJ�1 A,j�f/�.��(
PITSAND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK hit?! ts!
PRIVATE DISPOSAL SYSTEM ,L
SEPTIC TANK,SEEP,PITISI �� y
CONNECT ADDITIONAL BLDG,OR AND/OR DRPINFIELD
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL'Q DRYWELL❑
EXTN.,CES SPOOL,D RYWELL,MANHOLE
ALTER.REPAIR OR ABANDON HOUSE ALTER,REPAIR.SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANK5❑ � / ( i�}����qq��//'�"�ffgg_
_� _- SEEP,PITISIO CESSPOOLS (rJ ZQ/J/ L20•d(Iaan
OWNER'S Permit B
AUTHORIZATION I TOTAL FEE _ U �uL VALIDATION'
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- '�/1 • , 51514 A
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING '/
TO THE PUBLIC SEWER.
SIGNEDTHIS DAY OF 19_ ' M O O e D 1� 0
OWNER OR I
OWNERS AGENT I/ {1'�p�f� /_�/ 2
ADCIRESS /•~! /l S.MA�Y ��?i 2 0 - 3200
'1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION �! Y / O O O 3 2 0 0 r
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLYdl
�.fT ��`-a I
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING (� F/
PLL M BING ANDSEWERS. 9626-79 L Ij (,�•T(T
1 HEREBY CERTIFY THAT I AM PROPERLY REGI5T ERE D AND/OR PGVV / ``ll
LICENS EO AS REQUIRED BY LOS ANGELES COUNTY AND STATE OFA / �y�HR AORTHAT I AM THE LEGAL OWNER OF.ANOINTENDTO RE- LI / Gf (✓�
SIDE IN, EABOVE OESCRIOEO pE51DENTIALP OPERTY.
SIGN
,OF MITT