HomeMy Public PortalAbout10114 LA ROSA DR_Sewer__ S5&:-642D° ILS$ APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND.SAFETY SEWER-SEWAGE DISP.OSAL_,
Depaxtment of County Engineer
County of I:oa;Angeles _ - UiTDINc -
�s+ "-ADDRESS - ,••/ .
JOHN A £ANIBIE COUNTY ENGINEER y
._
® GASSATTO GRIFFIN .BUP.i of Burcolrvc a LOCALITY
_,.. - J r
NEAREST
FOR APPLICANT. TO FILL IN CROSS ST., s .
DESCRIPTION LOT NO. OWNER
../7 , / MAIL -
BLOCK /..'• TRACT / o )/ ADDRESS
NO. OF BLDGB. CITY /, ;� Tk RIO.
OF LOT NOW ON LOT`
USE OF DISTRICT NO. - GR P MAP "
BUILDINGS BK PG
CONTRACTOR r 7 6
ADnREss — CONNECTION DATA
CITY \ TEI. NO �. .1 STATION v- DEPTH -
{! MANHOLE REFERENCE ��..
❑ STATE LVVrrR'-.
,REGISTRATION NO. - ❑ COUNTY - /i✓ '•n/]�)�'
No. DESCRIPTdON OF WORK - FEE- r i-l-
i HOUSE SEWER CONNECTING TO �.• TYPE.O TION LENGTH.FROM
Y. CURB ..P.L. M.L. TO P.L.
PUBLIC SEWER. @ $3.50 -
SEPTIC TANKy SEEPAGE PIT OR
'PITS`AND/OR GRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELO CO. IMP. JOB NOOK
E%TN ,CESSPOOL,DRYWELL,MANHOLE @ $.2.00 ]� -
ER
PRIVATE DIHOUSE ISPOSAL SYSTEMG TO - @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO /3:/
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT Q
WORK TO HOUSE SEWER @ s LOG PERMIT NO
ALTER REPAIR OR ABANDON HOUSE _ INDUSTRIAL '
�- '.� SEWER OR DISPOSAL SYSTEM @ 51.00 WASTE APPROVAL. '
CHA ,ESS •.
I- CONNECTION CHARGE FEE
OWNER'S PERMIT 1 DO
FEE' -
I AUTHORIZATION TOTAL FEE ,a(� _REIMBURSEMENT
I HAVE AT THIS DATE A CONTRACT WITH THE.HEREIN ME O CON- APPROVALS' DATE INSPECTOR 5$IGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING —LL TO THE PUBLIC TO CONNECT ,- NEW HOUSE SEWER i
SIGNED?HIS 4 DAY,OF'- i CONNECT ADDITIONAL
'OWNER -OR „ <.. �., - -:. BUILDING;OR WORK .- .. _
OWNERS AGENT _ SEPTIC TANK,SEEP PIT(S)
ADDRESS �� s ANO/OR DRAINFIELD "
I HEREBY ACKNOWLEDGE THAT' [::HAVE READ TRIS.APPLICATION CESSPOOL❑ QRYW ELL❑
AND';STATETHAT THEI;ABOVE )$_CORRECT AND AGREE=-TO"COMPLY E-- -
,'WITH'ALL COUNTY: ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR;'SEWER OR -
�PLUMBING AND' SEW ERS ., ,.-,SEWAGE DISPOSAL,SYSTEM
LICENSED
AS REQUIRED-By
ETHAT—[ AM: PROPERLY •REGISTERED. AND/OR DISCONNECT'PLUG'-AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND,STATE OF gBANDON
HOUSE SEWER
CALIFORNIA OR T AM THE LEGAL OF THE ABOVE _
.DESCRIBED RESI 1 L P OPERTY:' 2 r " BACKFILL SEPTIC TANKB❑ -
"* �SEEPI PIT($) ❑tESS P00 L6 A
`SIGNATURE ���JJJ t a + a'- -
� ,OF�PERMITTEE ._ �" a �.,i• .••' ... .:
JOHN P:S LA131BIE. COUNTY'ENGINEERa .VALIDATION ROBERT A. WOOD,CHIEF PLBG. INSPECTOR
CK __: N 0 ..CASH �. .
2y+5 5"� FEB 6. 4 to