HomeMy Public PortalAbout10035 LA ROSA DR_Sewer__ Caoa-D
cAPPLICATION FOR PERMIT
Eaoe a-sa.' COUNTY OF LOS ANGELES
SEWER—SEWXE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE, County Engineer
CASSATT D. GRIFFIN, Sup't of Building LOCALITY -
NEAREST
FOR APPLICANT TO FILL IN caoss STT:
LEGALyy
DESCRIPTION LOT NO. —4 OWNER
BLOCK A TRACTMAIL-
ADDRESS ✓
N0. OF BL GS.
SIZE OF LOT NOW ON LOT C .CITY TEL. NO.
USE OF
BUILDINGS DISTRICT N0. GROUP I MAP P OCESSED BYYY
CONTRACTOR / - / � T LK. �� O(W J
ADDRESS g„L , _ CONNECTIONDATAL
CITY TEL NO. / i' -) STATION DEPTH
STATE
REGISTRATION NO. I SS�3 4 COUNTY MANHOLE REFERENCE UPPER.
NO. DESCRIPTION OF WORK FEE /� LOWER
HOUSE SEWER CONNECTING TO a; o 57 ?
PUBLIC SEWER @ $3.00
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM T—
PITS AND/OR DRAINFIELD - @ $3.00 Y. CURB
614 P.L. P,L,
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ 52.00
HOUSE SEWER CONNECTING TO P. NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 C P. NO. J 0.
CONNECT ADDITIONAL BLDG.OR Q
WORK TO HOUSE SEWER @ $1TRUNK PERMIT N0. ROAD PERMIT NO.
.00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO. -
2— 4ZCL41 INDUSTRIAL _
WASTE APPROVAL
CHARGES
OWNERLS PERMIT E 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE Q REIMBURSEMENT'FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE - INSPEC70R'S,BIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS Y OF IS_ NEW.HOUSE SEWER
OWNER OR i/ CONNECT ADDITIONAL A
OWNERS AGENT VV BUILDING OR WORK
SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS DI
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING p ALTER, REPAIR, SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY-THAT I-AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REOUIRED BY'LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 .AM THE LEGA N OF THE ABOVE
DESCRIBED RESIDE TIAL PRO E Y. BACKFILL SEPTIC TANKS ❑
91GNATURE / ( SEEP. PITS ❑ CESSPOOLS ❑
OF PERMIT Fr
®r ALIDATION - ROSERTA.WOOD
cK.
V.o. CASH SUPERVISING MECHANICAL ENGINEER
�ttio 7 3 6 5 T, 140Tv 12 0 n 4 .00