HomeMy Public PortalAbout10027 LA ROSA DR_Sewer__ CEBOB0 APPLICATION FOR PERMIT/00 -2-
""'° COUNTY OF LOS ANGELES SEWER-SEWA E ,DISPO A 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 'ni'Deelss d 2 : - r✓'OS a.
IOIra-A.
N A. LAMBIE. County Er. -
WILLIAM A. IENSEN. SuI'l of Bu,IZV LOCALITY
NEAREST ., '
FOR APPLICANT TO KILL IN .CROSS ST.
A
LEGAL OWNER
DESCRIPTION LOT N0. MAILS
BLOCK TRACT .G ADDRESS -3 I=L-1� C
NO.OF BLOGS.'X to rl
SIZE OF LOT NOW ON LOT. CITY TEL. N0.
USE OF '' DISTRICT NO. GROUP MAP NO ESS Y
BUILDINGS q S
BK PG
CONTRACTO7 •/•2 �� / I J ,�. nU
ADDRESS CONNECTION DATA Y
CITY TEL.NO. eoq�Q ATION
STATE .MANHOLE REFERENCE _ UPPE
REGISTRATION NO. C'J �/J 7�� COUNTY Y
NO. 1 DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK.SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
30
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT.UNAI NFIELO
EXTN..CESSPOOL. DRYWELL @ $2.00 _
''J P.C.NO.
HOUSE SEWER CONNECTING TO CO. IMP. NO. J JOB N0. „
PRIVATE DISPOSAL SYSTEM @ 81.00
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT N0. 0
WORK TO HOUSE SEWER @ 81.00 3�� U
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO. m
INDUSTRIAL U
WASTE APPROVAL N
CHARGES m
OWNER'S PERMIT j Q 30 CONNECTION CHARGE FEE rl
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MEO CON- _
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTIN DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. / y
SIGNED THIS DAY t` f IC191 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERSAGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I AVE MfADAHIS APPLICATION
AND STATE THAT THE ABOVEISCORRECT AND AGREE TO COMPLY CESSPOOL.❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING pLTER,.REPAIR,SEWER OR
PLUMeRS. SEWAGE DISPOSAL SYSTEM
1 HTHAT I AM PROPER REGISTER D AND/OR DISCONNECT PLUG AND
LICERED BY LOS "GE
OUNTY A STATE OF ABANDON HOUSE SEWER-
CALIT I AM THE L OWNE 0 THE ABOVE
DESCAL PROPERTY. BACKFILL SEPTIC TANKS
SIGN SEEP. PIT(S) ❑ CESSPOOLS ❑
OF PERM] EE
®. f VAL ROBERT A. WOOD
DK. M..0.0. GSH. SUPERVISING MECHANICAL ENGINEER.
( h I4 7 6 2hub' 61 J D 5.0 J .
,15&E.GD APPLICATION .FOR PERMIT
1
�6AE66DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
5
Deportment of County Engineer _
County of Los Angeles BUILDING /'
WM. J. FOX, COUNTY ENGINEER ADDRESS' `L- I
CASSATTD. GRIFFIN,-SUP•T OF BUILOINc- LOCALITY Y '"1 1 1
FOR APPLICANT TO FILL IN NEAREST
CROSS
T.
LEGAL . - �•. i --
DESCRIPTION LOT NO1111W. OWNER
BLOCKTRACT �I oee -j MAIL
N0. OF BLOTS, A GORES, Za'o
SIZE OF LOT NOW ON LOT CITY TEL. N0.
USE OF
' r
BUILDINGS DISTRICT NO._� GROUP BMAP
K PG
CONTRACTOR _ 4)-
ADDRESS G,I� �' �j CONNECTION DATA
CITY. DEPTHSTA
❑ STATE UPPER REFER ENC LOWER
REGISTRATION N0. ❑ COUNTY (!J
c
TYPE CO ECTION LENGTH FROM
No. DESCRIPTION OF WORK FEE Y. � CURB P.L. M.L.TO P.L.
HOUSE SEWER CONNECTING TO (�U
(_ :PUBLIC-SEWER O S 3.50 J ;
HOUSE SEWER CONNECTING TO .'
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO._IMP. NO. 13 I JOB. NO.
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING , 7 7 3 7
I
ALTER
OR DISPOSAL SYSTEM LN
00 TRUK,PERMIT N0. ROAD,PERMIT N0. J s7
DISCONNECT AND ABANDON SEWER STATE:ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
-SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL —' WASTE'-APPROVAL
>SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
'OWNER'S' PERMIT 8 1 00
AUTHORIZATION TOTAL FEE - F REIMBURSE14ENT FEE
I HAVE THIS .DATE.CONTRACTED WITH THE- HEREIN-NAMED CON- -
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS BATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
7 -
SIGNED THIS 2- �/ NEW HOUSE SEWER
� AY OF - � ^7
i
OWNER ' OR CONN ECT AD DITIO NAL
OWNERS AGE.TZ BUILDING OR WORK
ADDRESS d SEPTIC TANK. SEEP, PIT(S)
� - AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT41/HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE-THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
.PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR - DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT
USE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE-ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
PIT(S):Q_CESSPOOLS
SIGNATURE
OF PERMITTEE r l• ✓// j/
WILLIAM J.-FOX, COUNTY ENGINEER VALIDATION -'--
BY
`4 DEPUTY :,.t�O 3 _3 -)�irOi APR _) 4 4.5,0 DERBTT
BY
:y® DEPUTY .DEPUTY