HomeMy Public PortalAbout9066 HERMOSA DR_Sewer__ TBABA2
CEBOB 0 B-BB APPLICATION FOR PERMIT
� -
i COUNTY OF LOS ANGELES SEWER-SEWAGE, DISPOSAL
DEPART'M'ENT OF COUNTY ENGER`
INE , _ .
BUILDING AND SAFETY DMSION - 'BUILDINGq �j .
ADDRESS „p) jJjj IiL+t.r
' ASSN A LGRIFFI County Engiaeer, - -
CASSAS'D D GRIFFIN.-Sup t;.1 HuRil ausg LOCALITY n
'NEAREST %x �;:- �'
R _ FOR APPLICANT-TO'FiLL!lN . ` - CROS! ST:
.. .LEGAL -.- _ ',.` f-f/ / -..�-L- /
.DESCRIPTION LOYNO �/+: _-. OWNER f
MAIL
;BLOCK�.f� .TRACT . . + AD RESS a`41
.-
'SIZE OF LOT rte. NOW ON LOT /CITY: ��t TEL. NO. F" ., r7
USOF
'BUE DINGS / - �� 'DISTRICT N0. GROUP MAP PROCESSED BY.
BK
CONTRACTOR /�I I I I IPG?.
44
ADDRESS rI i^ r:' ' J's•:' - CONNECTION DATA
CITY .v.1 i. ^TL.,NO. .�W j... rt+IPGr✓ STATIONG±�,Y'-•rl C'� .DEPTH.. yT ., .
y ,.. STATE MANHOLE REFERENCE r � 'SUPPERB
REG
IlTRATION NO. f f" - -/Y/J "� COUNTYf—LOWER'?
NO. DESCRIPTION OF WORK! +- FEE
HOUSE SEWER CONNECTING TO `-
6 PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
j. SEPTIC TANK,SEEPAGE PIT OR - Y. /CURB X P.L. M.L.TO P.L. m.J
OVERFLPITS OW
DRAGS PIT.
@ $3.00 \.rte
OVERFLOW SEEPAGE PIT. DRAINFIELD
E%TN..CESSPOOL.DRYWELL C 52100HOUS ' r.�ss
s
_PRIVATE
q VATE DISPOSAL SYSTSEWR EM NG TO @ $1.00 CO.IMP. NOJ rt •'r T JOB NO.
^0 CONNECT ADDITIONAL BLDG.OR - ^+.
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO:X
I"- ALTER.REPAIR OR ABANDON HOUSE - STATE'ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
t^i INDUSTRIAL
-WASTE•APPROVAL
- CHARGES
' O.WNERt- PERMIT �s Z. -00 ^ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL. FEE
-� .�%i REIMBURSEMENT FEE
�I HAVE-AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON-
.TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING o"ELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SE ER. '
SIGNED THIS ,�,7 DAY+OF �� '�y/y- 19t!°'1 � xEw HOUSE SEWJ
FOW NERS AGENT ��� i -/ ' J{ -+f�"-v ^4+� CONNECT ADDITIONAL
�iP"_-, . +} �yy - BUILDING.ORWORKI
^-ADDRES SEPTIC TANK,SEEP: PIT(S)
~ AND/OR.DRAINFIELD
C HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION'S :..I;
AND STATE THAT.ITHE'ABOVE IS CORRECT ANDAGREE TD COMPLY .4
,-WITH ❑
WITH ALC COUNTY ORDINANCES AND STATE.LAWS REGULATING ALTER`REPAI R,SEWER OR PLUMBINGAND SEWERS: }•- SEWAGE•DISPOSAL SYSTEM
j, 1,HEREBY CERTIFY THAT1 AM -PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSEU�AS REQUIRED BA(. LOS ANGELES COUNTY AND,STATE OF ABANDON HOUSE SEWER
4CALIFORNIA OR THAT 1- M THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC.TANKS L
` ., _ SEEP. PIT(S) L CESSPOOLS L
SIGNATURE
A'OF,.:PERMITTEF'5.�-:p
®' 'V'ALIDA'TION`-' ROBERT A. WOOD
ii BK. - tl 0; - GASN� SUPERVISING-MECHANICAL ENGINEER
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