HomeMy Public PortalAbout9034 HERMOSA DR_Sewer__ CE80810-63 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE, County Engineer ADDRESS
WILLIAM A. IENSEN,.Supt at Building.
LOC -,TY
NEAREST
FOR APPLICANT TO FILL IN
ROSS BT. _
LEGAL /{—
DESCRIPTION LOT NO. / OWNER '
MAIL
BLOCK TRACT t gDORE55
NO. OF SLOGS. j
[DDRESS
OF LOT NOW ON LOT CITY 1� TEL. NO.
INGS I C DISTRICT NO. GR/O/VAP MPP PROCE5SE Y
RACTOR j 01 Y .
CONNECTION DATATATION DEPTH
/ f TEL. NO.
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. COUNTY
NO. DESCRIPTION OF WORK FEE TYPE OFC C O LENG HFRO
HOUSE.5EWER CONNECTING TO Y. CURB P.L. M.L,TO P.L. }
PUBLIC SEW ER ® E9.00
SEPTIC TANK,SEEPAGE PIT OR O
PITS ANJOB NO.O/OR DR.INFIELD 510,00 CO.IMP. NO.
U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM ® E3.00 p(
j - CONNECT ADDITIONAL BLDG.OR AFFIDAVIT My [.5[x[xi RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER 33.00
OVERFLOW SEEPAGE PIT,GRAINFIELD W
EXTN,.CESSPOOL,DRYWELL.MA NHOLE® ES,DO y
HWY.OR ST.WIDENING
ALTER.REPAIR DR ABANDON HOUSE VI
SEWER OR DISPOSAL SYSTEM E3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s z o0
AUTHORIZATION TOTAL FEE n/1 CONNECTION CHARGE FEE
�'IN 'REIMBURSEMENT FEE
'1 HAVE AT THIS GATE A CONTRACT WITH THE HEREIN N MED CON-
TRACTOR-TO^CONNECT THE ABOVE DESCRIBED EXISTING DWELLINI APPROVALS
TO THE PUBLIC
ER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS D OF_� � QT
�1 5
OWHEROREW HOUSE SEWEROWNERSq ENT ONNECT ADDITIONALADDRES k' UILD ING OR'WORK
EPTIC TANK,SEEP,PITIS)
I HE BY ACKNOWLEO E THAT I HAVE RE THIS RPP KATIOND/OR GRAINFIELD
AND"'STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATIN
PLUMBING AND SEWERS. CESSPOOL ❑ ORIWELL ❑
I HEREBY CERTIFY TF AM PROPERLY EGISTEREO RNO/OR ALTER.REPAIR.SEWER OR
LICENSED AS REOUIR Y A
C UrvTY AND BTAT OF SEWAGE D13P03AL 3YSTEM
CALIFORNIA Op THAT 'AM TMN R OFANDNTTO,RESIDE IN, THE' B DESCN IAL ERTY [ 'BBC D N H PLUG AND
ABANDON HOUSE SEWER
SIGNATURE,
OF PERMITT C BACKFILL.SEPTIC TANKS ❑ per.
SEEP. PIT(5) ❑ CESSPOOUS F* wAl
IDATIO ROBERT A. WOOD
CK. 1 ..0. CASH SUPERVISING MECHANICAL ENGINEER
C. A g , 1 AUG 19 1 0 7.00-
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