HomeMy Public PortalAbout9119 HERMOSA DR_Sewer__ TBA 642D - CEBOR - 8/73 APPLICATIO FOR P MIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY Temple it
FOR APPLICANT TO FILL IN c ossSST,
LEGAL Troxel
DESCRIPTION LOT NO. p Cl OWNER
,/ MAIL
BLOCK TRACT y ADDRESS same
NO. OF LDGS. 20[_.] 1.
SIZE OF LOT NOW ON LOT CITY TEL. NO. Vl L Y
USE OF DISTRICT NO. GROUP MAP PRO SSED Y
BUILDINGS resid. .K P5
Univeesal Plumbing
CONTRACTOR O
ADDRESS 2631 Lee Ave. [ J�� \•//AA' V CONNECTIONDATA
CITY So. El Monte TEL. NO.S7544+ STATION DEPTH
STATE LIC MANHOLE REFERENCE UPPER
LICENSE N0. O OLA.$ LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y, CURB P.L. M.L.TO P.L.
PUBLIC SEWER ® $7.00 P.C.NO
SEPTIC LANK,SEEPAGE PIT OR JOB NO,
PITS AND/OR ORAINFIELD Q 510.00 CO.IMP. NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM ® 53.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT AIV [ASNNx. RECORD.INSTR,NO. DATE
WORK TO HOUSE SEWER ® 53.DO (L.
OVERFLOW SEEPAGE PIT.GRAINFIELD 0
EXTN..CE$SPOOL.ORYWELL. Q 53.00 _/ U
ALTER.REPAIR�GR�RBANDON HOUSE HWY.OR ST.WIOENI NO j Q'l ✓ f/'f� yi
SEWER OR.OMP•BNL SYSTEM $3.00 STATE ENCROACHMENT _
U
MANHOLE p $7.00 PERMIT NO. W
INDUSTRIAL a
WASTE APPROVAL N
00
OWNERS PERMIT S CHARGE.
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE ACONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORN
SEPTIC TANK.SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ANO/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULAP.AC
PLUMBING AND SEWERS. L ❑ DRYWELL ❑
I HEREBY CERTIFY THAT M PROPERLY REGISTERED ANDPAIR.$EWER OR
LICENSED A$ REOUIREO BY 5 ANGLE COUNTY AND STATEDISPOSA L S Y$TEM Y
CALI FC NIA OR THAT A E LEGAL R OF. AND INTENDECT PWG AND
RESIDE IN. THE ABOVE CRIBEO RES E TIAL PROPERTY. HOUSE SEWER
SIGNATURE
OF TURF E SEPTIC TANK5 ❑
I51 CE53,a.
ALIDATION CK. M.O. CASH
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ri . • • AD
p, 0.
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