HomeMy Public PortalAbout10125 LA ROSA DR_Sewer__ 7BABA2D EROS APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF C6WITY ENGINEER
BUILDING AND SAFETY DIVISION F
DING 'I
10HN A. LAMM, Corny EegqiunBew REgs ...A �';� f"
WILLIAM A. TENSER. SMP! of Bmldmq' ... y
' LITY
RE6T /
FOR APPLICANT TO FILL IN LEcgL
DESCRIPTION LOT NO. Q ,6LrERDOCK . TflACTja/ RESS
NO. OF BLDGfC
SIZE OF LOT NOW ON LOTCITY TEL. NO.
USE OF YJ
BUILDINGS ^ �:l y4D /" DISTRICT NO. GROUP MAP PROGE60ED By
.� BK PGCONTRACTOR '�'ADDRES6 ! j ; _ _ CO CTIONDATACITY9LATION �, DEPTH
,yATE MANHOLE REFERENCE
REGISTRATION NO. :/ !' � COUNTY NO. DESCRIPTION O W RK FEETYPE OF CONNECT1pN L[NGTH FROMOHOUSE SEWER CONNECTING TOY. ¢UR J P.L. M.L.TO P.L. 1 +yPUBLIC SEWER O $5.SEPTIC TANK,SEEPAGE PIT ORCD.IMP.NO.PITS AND/OR GRAINFIELD O 8.OHOUSE SEWER CONNECT...TOTRUNK PERMIT NO. ROAD PERMIT NO.PRIVATEDISPOSALSYSTEM 83.CONNECT ADDITI ONAL SLOGORAFFIDAVIT WAIVES VAMUMIT RECORD.IXSTR.NO. DATE
WORK TO HOUSE SEWER 83.OVERFLOW SEEPAGE PIT.DRAM FIELD EKTN.,CESSPOOL.ORYWELL.MANMOLEY 85. NWY.OR BT.WIDENINGALTERREPAIR OR ABANDON HOUSESEWER OR DISP05AL SYSTEM O f96TATE ENCROACHMENT APERMIT NO.INDUSTRIAL deWASTE APPROVALCMAROEB
OWNER'S PERNRT 2 00AUTHORIZATION TOTAL FEECONXECTION CHARDS FEEI HAVE AT THIS DATE A CONTRACT WITH THE NMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED DWELL ING �T�}�pTO THBFPUSLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED-TH IS DAY OF 19_
OWNER ORNEW HOUSE SEWER
pp OWNERS ADEN T
CONNECT ADDITIONAL
Ii ADDRESS BUILDING OR WORK
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OTANK. IFIELOIT IB)
• AND/OR GRAINFIELD
(� ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DgYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT,A.AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ASOVE-,DESCRIBED REBTI�ENTIA PROPERTY.
!, ABANDON HOUSE SEWER
SIGNATURE 5
OF PERMITT F J' �- {:� BACKFILL SEPTIC TANKS ❑
SEEP,PIT(8) ❑ CESSPOOLS
VALIDATION ROBERT A. WOOD
CKM.o. .y .ABH MS�UUPERVISING MECHANICALS ENGINEER