Loading...
HomeMy Public PortalAbout9057 HERMOSA DR_Sewer__ 44650 INSERTS CEAPPLICATION FOR PERMIT JfiAS42D 642D COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL _ DEPARTMENT OF COUNTY ENGINEER - BUILDING AND SAFETY DIVISIONBUILDING 'ADDRESS iiOHN A. LAMBIE, County Engineer 1VILLiBM A. IENSEN, Suet of Building LOCALITYHEAR - FOR APPLICANT TO FILL INCROSIST O FILL IN � S IT. LEGAL OESCRI PTI ON LOT NO. OWNER - y BLOCK TRACTS MAIL ADDRESS NO.OF _LOGS. 1 SIZE OF LOT NOW ON LOT CITY TEL NO, USE OF DISTRICT NO. GROUP MAP PROCESSED BY BUILDINGS / -�JI1 BB=_ PG CONTRACTOR , �- �, ©�' I N ADDRESS ' , 2CONNECTION DATA CITY N0. t STATION DEPTH [] STATE 'MANHOLE REFERENCE �J REGISTRATION NO. ❑ COUNTY LOWER NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO PUBLIC SEWER @ $3.00 & TYPE OF C� N�! TION LENGTH FROM SEPTIC TANK,SEEPAGE PIT OR Y. RB I P.L. M.L.TO P.L. PITS AND/OR DRAINFIELD @ $3.00 OVERFLOW SEEPAGE PIT, DRAINFIELD EKTN.. CESSPOOL DRYWELL @ $2.00 HOUSE SEWER CONNECTING TO CO.IMP. NO. PRIVATE DISPOSAL SYSTEM @ SL00 A CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. - V WORK TO HOUSE SEWER @ $1.00 ALTER OR DISPOSAL ABANDON HOUSE @ $I OO STATE ENCROACHMENT PERMIT NO. O INDUSTRIAL .. WASTE APPROVAL w CHARGES - OWNER'S PERMIT $ Q 00 CONNECTION CHARGE FEE AUTHORIZATION I TOTAL FEE (D 0 REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. TRACTORTOCONNECT THE ABOVE DESCRIBED6TING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE TO THE PUBLIC $ ER. �y 1 SIGNED THIS OF 19 �`/ NEW HOUSE SEWER OWNER ORa CONNECT ADpi T ZONAL OWNERS AGENT ^ �.p .BUILDING OR WORK ADDRESS a SEPTIC TANK,SEEP.PITS) AND/OR DRAINFIELD 1, HEREBY ACKNOWLEDGE THATLHAVE,.READ'.THIS..APPLICATION.. AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL C3 DRYWELL Cl WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,.SEWER OR PLUMBING AND SEWERS. -' SEWAGE DISPOSAL SYSTEM 1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR pISCON NECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSES AND CALIFORNIA OR THAT 1 AM THE LEGAL.OWNER OF THE ABOVE DESCRIBED RESIDIEtiTIAL PROBACKFILL SEPTIC TANKS El / I / J SIGNATURE (Vy SEEP.PIT($) El CESSPOOLS 0' �I��L 1,14 14, �l OF PERMITTE (� ALIDATION - - ROBERT A. WOOD b.b, usR SUPERVISING MECHANICAL ENGINEER- LIivO d a 1 3 &131 1 0 '5 .0