HomeMy Public PortalAbout10108 LA ROSA DR_Sewer__ 76At4,D
E00B Rj� °"R' APPLICATION FOR PERMIT
o,
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT No. CRO-fzjUP MAP vxo seD By
71 ABUILDING
DDRESS 10108 La RosaL01, br ~ i�E
LOCALITY Temple City CONNECTION DATA
NEAREST STATION DEPTH
CROSS ST. LLML l UPPER
MANHOLE REFERENCE '
LOWER
OWNED Hammer TYPE OF CONNECTION LENGTH FROM
MAIL 10108 La Rosa CURB P.L. M.L.TO P.L.
ADDRESS
N� (1 I1 P.C.NO.
CIT1Lem le Cit II4 TEL.NO. �-� - 81 CO.IMP.NO, JOBNQ
LEGAL 0TRUNK PERMIT NO, ROAD PERMIT NO.
DESCRIPTION LOT NO. U-,L� /
O �� AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT,
NO.O SLOGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USEOF resid.
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
CONTRACTOR Universal Plumbing INDUSTRIALWASTE APPROVAL
ADDRESS 31 Lee Ave . CHARGES
2.
CITY o 4A. & 575--3 O CONNECTION CHARGE FEE
ATE LIC ENSE NO. - 16018 CLASS v 6&C 20 REIMBURSEMENT FEE
LICENSE
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE (�
HOUSE SEWER CONNECTING TO
PUBLIC SE WER O
NEW HOUSE SEWER
SEPTIC TANK.SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD 4AN
NNECT ADD RIO NAL G
HOUSE SEWER CONNECTING TO ILDING ORWORK GW
PRIVATE D15POSAL SYSTEM
CONNECT ADDITIONAL BLDG.OR PTIC TANK,SEEP,PITI51WORKTO HOUSE SEWER D/OR ORA INFIELDOVERF OW SEEPAGE PIT.GRAINFIELD SSPOOL ❑ DRYWELL❑
E MN..LESSPOOL,DRYWELL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE ALTER.REPAIR.SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑
OWNER'S Permit S SEEP,PITS)D CESSPOOLS L11
AUTHORIZATION I TOTAL FEE cL
VALIDATION
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AM DCON- A 2 L 11
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING 4 J V 11
TOTHE PUBLIC SEWER. y 1
SIGNED THIS DAY OF 19_ n 111, 0 110.
OWNEROR
OWNERS AGENT 2 • • 14.00
ADDRESS . • . 14.005
'1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING Or,02'-79
PLUMBING AND SEWERS.
I HEREBY CERTIFY THAT I A PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY O ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM T"E,L'EGAL OW OF,AND INTEND TO RE
SIDE IN,THE ABOVE DESCR4 ED RESID TI LPROPERTY.
SIGNATURE T.
OF PERMITTEE A.J"'L'C