HomeMy Public PortalAbout10122 LA ROSA DR_Sewer__ D
CESOS APPLICATION FOR PERMIT
casae ern COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING
ADDRESS
IOHN A, LAMBIE, CouatF Ea .er
CASBATT D. GRIFFIN. Supt oL Building. LOCALITY 7'
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNER
DESCRIPTION LOT N0. 3 MAIL
BLOCK TRACT loft ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. N0.
USE OF
BUILDINGS44 DISTRICT NO. GROUP BK MAP PROCESSED B�,
PG
CONTRACTOR 4� O
ADDRESS f-3 '—'� tJ CONNECTION DATA l
CITY S TEL.NO. Qi�� IOR�t DEPTH
/� >/ STATE MANHOLE. CE PPER
REGISTRATION NO. / Y / 1 L COUNTY
N0. DESCRIPTION OF WOR FEE '
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FRO
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.N0.
PRIVATE DISPOSAL SYSTEM @ SI.00 CO.IMP. N0. h JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ 31.00
ALTER.
OR ASYSTEM HOUSE @ $100 STATE ENCROACHMENT
PERMIT N0.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OVMER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINGAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. 1
SIGNED THIS D OF 19_ NEW HOUSE SEWER 6��
OWNER OR /J CONNECT ADDITIONAL
OWNERS AGENT Y�...!!!/NNV BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL El
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR SEWAGE
AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONABANDON CT PLUGAHOUSE D
CALIFORNIA OR THAT 1 THE LEGAL WNER OF THE ABOVE
ER
DESCRIBED RESIDENTIAL OPERTY. BAPKFILL SEPTIC TANKS ❑
SIGNATURE S P. PIT(S) Ll CESSPOOLS
OF PERMITTE
Or VALIDATION ROBERT WOOD
CK. M.o, ustl SUPERVISING MECHANIGL ENGINEER
L; 7 COT 1 5.0 0
°
CE808 B�rp
APPLICA ON FOR P RMIT
EpOB
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS Z v
JOHN A. I.rRIFIFIAMBIE, . SUP t .1 per
CASSAYC D. GRIFFIN.. $LLP! o! Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. 3 OWNER
BLOCK TRACTOOF B MAIL
N0. DGS. ADDRESS
SIZE OF LOT NOW ON LOT CITY TEL. N0.
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSE BY
RK PG
CONTRA
ADDRESS S CONNECTION DATA
CITY S G TEL.NO. TION DEPTH V ��
❑ COUNTY MANHOEjtEF.E@ENCE- P
REGISTRATION NO. [/�% `�/ B �YY.. s3_ly"�"
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK.SEEPAGE PIT OR CUR P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN., CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.N0. ,
PRIVATE DISPOSAL SYSTEM @ $I.00 CO.IMP. NO. JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ SI.00
SEWER OEDISPOSNL SYSTEM HOUSE @ $100 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE B O REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT— BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP. PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER.REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT AM PROPE Y REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED RY LOS ANGELES OUNTV A D STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT y M THE LEGAL 0 NER OF THE ABOVE
DESCRIBED RESIDIDENTIPERTY. / SAC Fp'T(S❑ TANKS
SEPTIC11 CESSPOOLS
SIGNATURE
OF PERMITTEE
®= VALIDATIOI�T--�-1 ROBERT WOOD
CK. Y.p. /lX / SUPERVISING MECHANICAL. ENGINEER
/G J.�.
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