HomeMy Public PortalAbout8903 HERMOSA DR_Sewer__ 610-fi3
AB4 APPLICATION FOR PERMIT
C E808 D
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION em Lmrvc
JOHN A. LAMBIE. County Engineer ADDflcss D•7) �� Q�
WILLIAM A. JENSEN. Supt o1 Building , 1 1
LOCALITY �'/J/I
N EAREv^T
FOR APPLICANT TO FILL IN EROSE ST.
LEGAL
DESCRIPTION LOT NO. ^' / O'NNER
MAIL
BLOCK TRACT A-DRE55 903 err»o Q Ave A
NO. OF SLOGS. `
SIZE OF LOT NOW ON LOT CITY^ Fh a EL NO.
USE OF
BUILDINGS 015TRIOT NO, GROUP MAP PROCESSED BY
BH PG
CONTRACTOR `
ADDRESS 3 j /(�� CONNECTI DRTA
CITY`- ' �yG� TEL NO. 3.s S' Z. STATION r 3 i DEPTH
STATE MANHOLEREFERENCEl
REGISTRATION NO. COUNTY O E
NO. DESCRIPTION OF WORK FEE TYPE OFTION LENGTHFROM
/ OUSE SEWER CONNECTING TO V. CUR F.L. >_M.L.T. O P.L.PUBLIC SEWER 0 $5.00 in 0
SEPTIC TANK.SEEPAGE PIT OR P.C.NO. 6
PITS ANO/OR DRAINFIELD 510.00 CO.IMP. NO. JOB NO. O
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM $3.00 TRUNK PERMIT NO. ROAD PERMIT NO. OC
®
CONNECT ADDITIONAL BLDG.OR ID VIT w/.I UIUIUU RECORD.INSTR.NO.
WORKTO HOUSE SEWER 53.00 p �
OVERFLOW SEEPAGE PIT.DRAINFIELD `I W
E%TN..CESSPOOL.DRYWELL.MAN HO LE(ip SS Do / d
ALTER.REP41.OR ABANDON HOUSE k.OR ST"WIDENING N
SEWER OR DISPOSAL SYSTEM 53.00 STATE ENC AC ENT Z_
PERMIT NO
INDUSTRI L
WASTE ROVA /1 I,1•
OWNERS PERMIT $ z Oo cHA
AUTHORIZATION TOTAL FEE GQ DNNECT1pN CHAR FE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE ^ ��
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER, APPROV LS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING
SEPTIC TANK.
WORK
$EEP,FI.L PIT(S)
1 HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION ARD/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREECOMPLY
WITH ALL COUNTY OROINA NC E$ AND STATE LAWS REGULATING
PLUMBING AND SEW EflS. CESSPOOL Cl ORV WELL ❑
? HEREBY 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 1 AM THE L GAL O ER OF, AND INTEND TO DISCONNECT PLUG AN
RESIDE IN, THE ABOV OESCRI ED 51 T...11fIAL,PROPERTY, ABANDON MOUSE SEW ER
SIGNATURE ♦ L`t t' .�p BACKFILL SEPTIC TANKS ❑
OF PERMITTEE_ ❑
SEEP,PIT(5) ❑ CESSPOOLS
VALIDATION ROBERT A. WOOD
cK. M.D. CASH SUPERVISING MECHANICAL ENGINEER
Lf1l,o3 6 1 7 (02 7 1 0 D 7.00- R'
CEROR3 . APPLICATION ' PERMIT [/II
CEA642D . "' II
COUNTY Of LOS ANGELES SEWER—SEWAGE DISPOSAL IILIII
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILD'
' O C
JOHN A. LAMBIE, County Engineer ADDREss
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESC RCPTION LOT NO.• // / / / / O V
OWNER
MAIL
BLOCK TRACT J / /� ADDRESS
-777 SIZE OF LOT C'4O NOW ON LOTS „( CITY ¢.Q L. NO.(i(+/
USE OF DISTRICT NO. ROUP MAP PROCE95ED BY
BUILDINGS
IK
CONTRACTOR
ADDRESS �^- CONNECTION DATA
CITY TEL. NO. STATIONDEPTH
STATE MANHOLEREFE RENCE Jr� ( UPPER
REGIBTRATIO NO. COUNTY
NO. DESCRIPTION OF WORK FEETYPE OFC CTION LENGTH
FROM
HOUSE SEWER CONNECTING TO , Q fl Y. CURB v P.L. M.L.TO P.L.
PUBLIC SEWER ® E5.00 X. P.C.NO,
SEPTIC TANK,SEEPAGE PIT OR CO.IMP.NO. _ JOB NO. O.
PITS AND/OR DRAINFI ELD ® EI0
.00 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROA.PERMIT NO. (J
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT v'Mvq 4[[M[xi ACCORD.INSTR.NO. DATE K
WORK TO HOUSE SEWER ® 33.00 O
OVERFLOW SEEPAGE PIT.GRAINFIELD
EXTN..CESSPOOL,DRYWELL.MANN OLE O $5.00 V
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING W
SEWER OR DISPOSAL SYSTEM ® 33.00H
STATE ENCROACHMENT
PERMIT
PERMIT NO, Z
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s 2 00
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE 00
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TO TH CONNECT
SEWER THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
DATE IN CTOR'B BI NATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK.SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE HEAD THIS APPLICATION ANO/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER .EPAIR.SEWER OR
LICENSE. AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO OISCON NECT PLUG AND
RESIDE IN. THE ABOV ESCRIBEO RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS ❑
EEEP.PIT(B) ❑ CESSPOOL
VALIDATION ROBE T A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK.
M.0. CASH
LAC0 4 0 4 U' APR 21 d D 7.0 0� a`
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