HomeMy Public PortalAbout10117 LA ROSA DR_Sewer__ &642E-6.31ia9 APPLICATION FOR PERMIT 1
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/IVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
`
County of Los Angeles BUILEING
- ADDRESS J Q'
JOHN A. LAMBIE: COUNTY-ENGINEER
® CASSATTD.GRIFFIN. SUWTOFBUILDING .LOCALITY
NEAREST
FOR APPLICANT TO FILL. IN CROSS sr.
y OWNER
A
:DI ESLRILEGAL PTION LOT N0.
MAIL
BLOCK TRACT /Q "L J ADDRESS
NO. OF BLDGS.1 / CITY TEL. N0..S;ZE OF LOT NOW ON LOT '
USE OF DISTRICT N0. GROUP ' MAP
BUSLDINGS C SK PG
CO�fITRACTONs i A. S Z
ADDRESS ` Z S +LJ �. } b,af ^CONNECTION DATA
/ STATION ' 3 DEPTH '
CITY /k L TEL. NO. [O 51(i(e S' MANHOLE REFERENCE /
u-• Q-STATE OWE •
REGISTRATION NO. �S'Z ❑ COUNTY _ -
'No. DESCRIPTION OF WORK FEE
TYPE OF CONNECT, LENGTH FROM
! HOUSE SEWER CONNECTING TO g J J Q, URB M L.TO P.L.
.' PUBLIC SEWER @ $3.50 S 7
SEPTIC TAN K('SEEPAGE PIT OR a ,
PITSANO/OR,RAI NFIELD @ $3.00 /
OVERFLOW.SEEPAGE PIT, GRAINFIELD P. C. NO /
EXTN ,CESSPOOL.DRYWELL.MANHOLE @ S 2.00 Ce_lMf"ffO` -I�'A�'•
HOUSE SEWERCONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERM[T•NO. ROAD PERMIT NO.
CONN ECT ADWTIIONAL B LDG.OR STATE ENCROACHMENT - -
WORK 7b HOUSE.SEW R @ S 1.00 PERMIT NO.
ALTER,AEPAIROR ABAN DO N HOUSE INDUSTRIAL
- -
"SEWERCR,DISPOS'AL'SYSJEM @ $1.00 WASTEAPPROVAL
CHARGES .
- - - - - -" CONNECTIONCHARGE FEE
-
OWNER'S pERMT $ T DU REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE 5-6
I APPROVALS DATE INSPECTOR'S SIGNATURE
7 HAVE AT THIS DATE A'CONTRACT WITH THE HEREIN`NAMED CON-
I TRACTOR. TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THI DAY OF 19— CONNECT ADDITIONAL
OWti
OR WORK
�° BUILDING 6R WORK.
OWNEMS AGENT _ e .. SEPTIC TANK.SEEP,PIT(S)
w
ADRES$— /OR DRAINFIELD
9 1 HEREBY ACKNO LEDGE THAT I HAV READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT SHE ABOVE.IS.,CORRECT.-AND AGREE IO COMPLY -
W,1TIF ALL COUNTY.ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. - SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY' THAT 1 AM PROPERLY REGISTERED .AND/OR DISCONNECT PLVO AND
,LICENSED AS REQUIRED, BY LOS ANGELE5 COUNTY AND STATE OF DIS HOUSE SEWER
LIFO RNIA OR TH AX_ I A THE LEGAL OWNER OF THE ABOVE ABANDON
I
DES-CR BEO RESYDENUAL P PER-TY. BACK F14L SEPTIC TAN NS❑
.SfGNAT.URE SEEP.PtT(S) ❑CESSPOOL$❑ '
k• gF;PERT,l
S,OHWAA. LAMBIE:.CO YENGIN'EER """ VALIDATION ROBERT A.WOOD, CHIEF PLBG. INSPECTOR
.. cj; ' - M.0. CASH - - -
9, 3 A9 i- :,IUB a 2 . . 4 4&0 n, -