HomeMy Public PortalAbout9011 HERMOSA DR_Sewer__ 9BAPPLICATION FOR PERMIT 1
e&E68fieDIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDINGADDRESS 9011 Heretos Drive,
JOHN A. LAMBIE. COUNTY ENGINEER
® CABSATTD. GRIFFIN. SUP•TOFBUn.mNG LOCALITY Temple CitY '
FOR APPLICANT TO FILL IN CROSSST. An. PfrlP.>:C" Riva.
LEGAL
DESCRIPTION LOT NO. SQ ' OWNER F;rvin N . Davi S
BLOCK TRACT S9ADDRESS O 1
1 reran a Dr,
SIZE OF LOT t (� NOW ON LOTS CITY TemT)le City TEL. NO. AT
USE DI DISTRICT NO. GROUP _MAP
USE
OF
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CONTRACTOR I,�ialer PlumbinE; Co. ,
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ADDRESS310 E. Huntington Dr, , CONNECTION DATA
CITY . Cd .`Z. TEL NO. 11 78146 STATION DEPTH
ly»
MANHOLE REFERENCE _ UPPER
STATELOWER
REGISTRATION NO.
77810 ❑ COUNTY E
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TOTYPE F CONNECTI N_ LENGTH FROM
PUBLIC SEWER @ Y. CURB P.L. M.L.TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $.3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. NO.
EXTN.,CESSPOOL.DRYW ELL,MANHOLE @ $2.00 CO. IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ S 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ S 1.00 'a PERMIT NO.
ALTER.REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ S 1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 21 00 � n,
AUTHORIZATION TOTAL FEE 00 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA ED CON- APPROVALS DATE INSPECTOR'SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ^ 'A ��
TO THE PUBLIC SEWER. NEW HOUSE SEWER //
SIGNED THIS DAY OF 19_ CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL ED DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF —ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AAI THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESID TIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATUREs SEEP. PIT(S) ElCESSPOOLSC
OF PERMITTE
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK M.0. CASH
[J&2345 SEP 81 OA 3.00 19