HomeMy Public PortalAbout9061 HERMOSA DR_Sewer__ DEOS 3 B -94
8 3 APPLICATION FOR PERMIT
CE
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Supt OE Building —�
LOCALITY t,
NEAREST
FOR APPLICANT TO FILL IN RDBB BT.
EGAL
DESCRIPTION LOT NO. ::z- OWNER CLQ
A� f MAIL
BLOCK TRACT _t5 4c�a ADDR ESB
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILOI NGS - (,. �/ DISTRICT,)NO. GROUP MAP8K pa PRQCEBBIO BY
CONTRACTOR
�E_/ - �' �.2 1 v (i '� k 4 \
AODREBB /(j 26 ��D tleFrF _ CONNECTION DATA
CITYz) /qq TEL. NO, �ry�O� STATION � /_, 3� DEPTHTATE
6C.3 of ` LJ COUNTY V I2 1jd UPVO�R
REGISTRATION NO. MANHOLE REFERENCE
PER
NO. DESCRIPTION OF WORK FEE TYPE OP CON CTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y, RB P.L. M.L.TO P.L.
PUBLIC SEWER ® $9.00 P.C. NO. }
SEPTIC TANK,SEEPAGE PIT OR CO.IMP. NO. l JOB NO. 1
PITS ANO/OR GRAINFIELD ® $10.00 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. U
PRIVATE DISPOSAL SYSTEM @ 53.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIV[II [AtrerNT RECORD. INSTq, NO. DATE O]
WORK TO HOUSE SEWER 0 $3.00 O
OVERFLOW SEEPAGE PIT,DRAINFIELD f
EXTN.,CESSPOOL,DRYWELL,MANHOLE 0 $9.00HWY, OR STWIDENING U
.
ALTER.REPAIR OR ABANDON HOUSE Q_
SEWER OR DISPOSAL SYSTEM $3.00t(:
STATE ENCROACHMENT N
PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT CHARGES
AUTHORIZATION TOTAL FEECONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE �7
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF I9_ P^ / J��
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
IHEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION ANO/OR DRAINFIELD
ANO STATE THAT THE ABOVE IS CORRECT AND AGflEE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR,SEWER OR
LICENSED AS REOUIREO BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I-AM THE LEGAL OWNER OF. AND NTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A OESCRIBEO REST TIAL PRO RtY.
1fN ABANDON HOUSE SEWER
SIGNATURE /`^/"/�� / `L� ,' Awe
�
I/,114!!."" (U/T2 VCCC��/ 'W BACKF IT SEPTIC) F1TANKS ❑
OF PERMITTF SEEP,PITIB) ❑ CESSPOOLS ❑
VALIDATION ROBERT WOOD
M.O. CASH
SUPERVISING MECHANICAL ENGINEER
CK.
LACc �.8 0 1�. FE8 18 1 0 D TO O" a
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