HomeMy Public PortalAbout10105 LA ROSA DR_Sewer__ CEBDSA4/]2 A P P LI CA N FOR P�T l l
TSAsatL COUNTY OF LOS ANGELES S WER—SEWAGE DISPOSAL u
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADORE
LOCALITY
NEAREST
FBLOCKTRACT
APPLICANT TO FILL IN CROSS ST.
OT NO. OWNERMAIL:27 3z 6 ADDRESS101Q9 LA R A
HOWOONBLOT$ CITYTEVTLE IEL. NO.
DISTRICT NO. GROUP MAP PROCESSED BY
^�J^, pK PG
CONTRACTOR J&D PL17149TNG
ADDRESS 414 SOo SANGABRIRT, CONNECTION DATA
CITY';AN TEL. NO, /� (�STAT STATION DEPTH 6 /yam
PER
LICENSE NO. CLASSY.4G �G y UPCTFIT
MANHOLE REFERENCE
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB .L M.L.TO P.L.
PUBLIC SEWER a }
P.C.NO. D
SEPTIC TANK.SEEPAGE PIT OR5- O
PITS ANO/OR GRAINFIELD CO.IMP. NO. JOB NO.
U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ CONNECT OBLDG.OR AFFIDAVIT Alv 0
saxsxi RECORD. INSTR.NO. DATE O
WORK TO HOUSE
SEESEWER ER a (—
OVERFLOW SEEPAGE PIT,GRAINFIELD U
EXTN..CESSPOOL.ORYWELL.A,ANMOLE® W
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING a
SEWER OR DISPOSAL SYSTEM ® STATE ENCROACHMENT I_
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE NSPECTOR'SSIG NATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING ORR WORK
OGRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANA.SIELD TIS)
AND/OR GRAINFIELD
• STATE THAT THE ABOVE ICORRECT AND ACOMPLY
WITH
H ALL COUNTY ORDINANCES
S ANO STATE LAWS
WS REE GULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYW ELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR.SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TODISCONNECT PLUG AND
RESIDE IN. THE ABOV DE RIBEO RE51 ENTIA PROPERTY ABANDON HOUSE SEWER
SIGNATURE 1 ❑
BACKFILL SEPTIC TANKS
OF PERMRTEE
- SEEP.PIT I$) ❑ CESSPOOLS ❑
VALIDATION
CK. M.O. ASN
0 2 3 BSEP 23 1 :3 0 1 5.0 0 •z)8
I
1
0,