HomeMy Public PortalAbout10039 LA ROSA DR_Sewer__ CE808 D /i�1���2��
IU-63
6A64 APPLICATION OR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILGINcQ�
JOHN A. LAMBiE, County Engineer ADDS Ess --/
WILLIAM A. JENSEN, Supt of Building
LOCA Li TY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL J L�A f
DESCRIPTION LOT NO. OWNER I
MAIL
BLOCK TRACT @y.L AODREBS/7 �y `f tj`�
NO. OF BLOCS. ✓✓✓JJ/
SIZE OF LOT NOW ON LOT CITY TEL. NO.
UBE OF _/
BVILOINGS DISTRICT NO. GROUP MAP PROCESSED BY
CONTRACTOR J^/ Jv Z' �v
ADDRESS , CONNECTION DATA
CITY (v P TEL. NO. ./� �Z� `� ATION // DEPTH
REGISTRATION NO. ^� � ( ❑ COVNTY MANHOLE REFERE`NICE A�}� LOWEp
NO. DESCRIPTION OF WORK FEE TYPE OF CONN CI LENGTH FROM
HOUSE SEWER CONNECTING TO Y. C PSL. M.L.TO P.L. }
PUBLIC SEWER ® 35.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. d
PITS AND/OR ORAINFIELO @ 5I0.00 CO.IMP, NO. JOB NO. O
V
NO ATE DIBE SER POSAL
NESTING TO TRUNK PERMIT NO. ROAD PERMIT O
PRIVATE OISPOSgL SYSTEM ® E3.00 G:
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wgY[v s[N[Ni RECORD. INSTR.Nd. DATE O
WORK TO MOUSE SEWER ® ".no F-
OVERFLOW SEEPAGE PIT,GRAINFIELD U
EXTN..CESSPOOL.GRYWELL.MANHOLE 0 $5,00 W
C,
ALTER.OOR ABANDON HOUSE HWY. B ID N 1 h
SEWER ERR ORR DISPOSAL SYSTEM ® E3.00 BTATE OACHMENT
PERMIT NO.
INDUSTRIAL /
CHAR ES
OWNERSPERMIT S z 00 /
AUTHORIZATION I TOTAL FEE A / CONNECTI N HARD F E
L
'I HAVE AT THIS DATE A TRACT WITH THE HEREIN rIAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT T E ABOVE OEBERUSE. EXISTING/DWELLING
TO THE PUBLIC R'S SIGNATURE
THIS SEWE
SIGNED , , APPROVALS DATE INSPECTOR'SDAY OF I
OWNER OR NEW HOUSE SEWER
OWNERS ADENT
- CONNECT ADDITIONAL
ADDRES
BUILDING OR WORK
S
1
HER ACK -LEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK.BFIELD T(51
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DflAINF1ELD
WITH ALL COUNTY ORDINANCES ANO STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES tOUNTY AND STATE OF SEWAGE DISP05AL SYSTEM
CALIFORNIA OR THAT I AM LEGAL O ER AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOV CR BE RE51 TI ROPERTYE. ABANDON HOUSE SEWER
SIGNATDRE BACKFILL SEPTIC TANKS ❑
OF PERMIT E SEEP,PITIS) ❑ CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
cK.
M.0. CASH SUPERVISING MECHANICAL ENGINEER
LAo 5 6 3 9-�r NOV 5 1 0 0 7.0 0-
610-63
A64 APPLICATION FOR PERMIT
C E808 D
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Bm LmNc A AwI /'.A
JOHN A. LAMBIE. County Engineer ADDRESS �a3 '44 ADDRESS �_(r
WILLIAM A. JENSEN, Supt of Building M //
LOCALITY �ili�l
NEAREST
FOR APPLICANT TO FILL IN `ROSS 5T.
EGAL
DESCRIPTION LOT NO. �j(� ./L 3/. I�.
I MAIL
BLOCK TRACT ADDRESS
NO. OF BLGS.
SIZE OF LOT NOW ON LODT CITY TEL. NO,
USE OF
BUILDINGS —4e s DISTRICT NO. GROUP OK MAP PROCESSED BY
PG
CONTRACTOR tln,.g
ADDRESS I ? reg ,40X .�3 47 CONNECTION DATA
Z
CITY - (��,��'� TEL. NO. �'� ! I'^A B TION DEPTH
/ r/e 7 ❑ STATE MANHOLE REFERENCE ` • E LOWER
REGISTRATION NO. I ❑ COUNTY IIEiLL_JJXFF
NO, DESCRIPTION OF WORK FEE TYPE OF CON E LENGTH FROM
HOUSE SEWER CONNECTING TO Y. P, M.L,TO P.L, r
PUBLIC SEWER ® SB.00
P.C.NO. d
SEPTIC TANK,BEE PAGE PIT OR CO.IMP, NO. JOB NO. O
PITS ANOIOq DRAINFIELD ® 31000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT
PRIVATE DISPOSAL SYSTEM 4 $3.00 I a O C
CONNECT ADDITIONAL BLDG,OR AFFIDAVIT I *IIVCR v31RIN. RECORD.INSTR.NO. DATE
WORK TO NOOSE SEWER 83.00 V
OVERFLOW SEEPAGE PIT.DRAINFIELp
EXTN_CESSPOOL,DRYWELL.MA OLEO 55.00
ALTEq,REPAIR Oft ABA DO SE H ST
SEWER Oq DISPOSAL 5 33.00 STATE ENCROACHMENT z
F. PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s
AUTHORIZATION TOTAL FEEANAMEDCON-
CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIREIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'B SIG NATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER -r t AGENT CONNECT ADDITIONAL
BUILDING OR WORK ,
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. ANO INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOVE ISED RE EN L PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMI E SEEP.PIT IS) ❑ CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK.
M.O. CASH
�f 5640:0 NOV 5 1 1 D 25.00