HomeMy Public PortalAbout10023 LA ROSA DR_Sewer__ ;24650 INSERT
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."°°8,6.50 APPLICATION FOR P'ERMiT
>snsazo COUNTY OF LOS ANGELES SEWER-SEWAGE .D.I.SPO.SAL—
DEPARTMENT OF COUNTY ENGINEER " BUILDING
BUDDING AND SAFETY DIVISION ADDRESS DdZ
TORN A. LIE, Cou.ty Evgqiu -
WILLIAMAMB
A. JENSEN• Supeert of Bvi7 9 LOCALITY '
NEAREST _ _.
FOR APPLICANT TO FILL. IN DROSS ST.
LEGAL A� OWNER: V. '
DESCRIPTION LOT N0. ( 0- _
BLOCK TRACT MAIL
ADDRESS
NO.OF DGS.
SIZE OF LOT NOW ON.LOT f CITY TEL, NO.
USE OF BUILDINGS DISTRICT NO. GROUP MAP PR CE55$dBY
- I
BK_
J
CONTRACTOR
.ADDRESS -y � �� ti CONNECTION. DATA -
CITY czTEL.N 0 AOION DEPTH
STATE MANHOLE REFERENCE UPP
REGISTRATION NO. COUNTY
No. DESCRIPTION OF WORK FEE Q
HOUSE SEWER CONNECTING TO &-vQ
PUBLIC SEWER CD° $3.00 TYPE OF CONNECTION -LENGTH F OM �,
SEPTIC TANK,SEEPAGE PIT OR Y. CUEl P.L. M.L.TO P.L.
PITS AND/DR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.. CESSPOOL DRYWELL @ S2.00 _ -
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSA L.SYSTEM @ 51.00. CO.IMP. N0. JOB N0. [^
CONNECT AL BLDG,OR
WORK C HOOUSESE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO. J' 13 a0
SEU
SEWER RI DISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENTof
PERMIT NO. O
INDUSTRIAL.
_ - WASTE APPROVAL W
CHARGES' N
OWNER'SPERMIT $ Q 00CONNECTION CHARGE FEE l p
AUTHORIZATION TOTAL FEE av
REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- ]tN+1
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERB AGE14T BUILDING OR WORK.
ADDRESS SEPTIC TANK,SEEP.PITS) -
AND/OR DRAINFIELD _
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS.APPLICATIONS --- - - - - --
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,:REPAIR.SEWER.OR
PLUMBING AND SEWER - SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIF THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED A3 RE RED BY LOS ANG 5 COUNTY AND'STATE OF ABANDON HOUSE'SEWER'
CALIFORNIA R HAT 1 AM THE AL OW ER OF THE ABOVE BACKFILL.SEPTIC TANKS'[]
NTIAL PROPERT N/I�/
SIGNASEEP.PESSPOOLS C
E .
OF PE MIT
VALIDATION ROBERT A. WOOD '
C& r /! M.O: CASK SUPERVISING MECHANICAL ENGINEER,.
LI.LO
4 7 5 9 `n' i'sUtli V C 5,C) Q Ir
'24650"INSERTS,
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C66.00 - APPLICATION FOR PERIVIFT <�
d>'16A642D A6420 .
COUNTY- OF LOS ANGELES SEWER—SEWAGE DISPOSAL .
DEPARTMENT OFCOUNTYENGINEER -"
BUILDING.AND SAFETY DIVISION BUILDING
oossG
MAMJOHN A. LAMBIE• Cvuvly E.S5w�ve°r
A A. JENSEN. S=i 01 Bvilddv9 LOCAL=
NEAREST
FOR APPLICANT TO FILL CROSS ST.
.LEGAL 1 _
DESCRIPTION LOT N0. OWNER Gtr
BLOCK TRACT MAIL -- ,
ADDRESS. ✓s/l.
I0.-0FBLDGS.
SIZE OF LOT NOI ON LOT I CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP I •PRO ESS BY
5�� I �BK^ PG
�
CONTRACTOR
ADDRESS oe� CO
v/ �. . NNECTION DATA
CITY 5 �. TEL.NO.
�¢ TION DEPTH
1 ,
REGISTRATION N0, �;y/ ❑ STATE MANHOLE REFERENCE
lJ J ❑ COUNTY �r
NO. - DESCRIPTION OF WORK FEE �•
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. LUR P.L. M.L.TO P.L. (./J
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINF.IELD
EXTN,. CESSPOOL. DRYWE LL @ $2.00
HOUSE SEWER CONNECTING TO -P.C.NO. -
PRIVATE DISPOSAL SYSTEM @ S1.00 CO. IMP. NO- - JOB N0.
,CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. p
WORK TO HOUSE SEWER @ SI.00 O
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWERO ISPOS L3 @ $1.00 :PERMIT NO. 0
INDUSTRIAL P'
WASTE APPROVAL W
CHARGES N
OWNERS PERMIT $ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE ,
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF - 19_ NEW HOUSE SEWER' - - -
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT y - BUILDING OR WORK- f '
ADDRESS SEPTIC TANK,SEEP.PITS) QQ !
AND/OR DRAINFIELD ,T o !
I HEREBY ACKNOWLEDGETHATI HAVE READ THIS APPLICATION - - ��f/�� �[•�(e,/r.
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY CESSPOOL Cl DRYWELL 0 BI'L✓ .dI .aAI'.'. ,
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,.SEWER DR
SEWAGE DISPOSAL SYSTEM
I .HEREBaRAT
THAT I AM PROPERLY REGISTER D AND/OR DISCONNECT PLUG AND
LICENSEDED BY LOS ANGELES COUNTY AN STATE OF
-- -
LICENSRN 1AM THE .LEG WNE OF THE ABOVE ABANDON HOUSE SEWERDESCRIBAL PROPERTY. BACKILL TANKS
SEEP. PIT(5)P OC CESSPOOLS E]
SIGNAT -OF PERMITTEE
®. CASH.
ROBERT A. WOOD
IL _
C ..M.°. usH. _ SUPERVISING MECH.4I•IIC:AL ENGINEER
(c4 7 6 0 NM 51 1 DD . -n-
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