HomeMy Public PortalAbout10127 LA ROSA DR_Sewer__ CEBOB 3-62 APPLICATION FOR PERF
TBAeazD. COUNTY OF LOS ANGELES ._
_ DEPARTMENT OF COUNTY_ENGINEER' , SEWER-S E,WAGE_DISPOSAL
BUILDING AN
M D SAFETY DIVISION BUILDING
IONN A. LAMBIE. County E 9 a"� w°DREss ®� ^'
f , WILLIAA. IENSEN,. Sup t f Building_ > -
Iff� _ )' LOCALITY Prrr ��� t
NEAPES "} J
' + FOR APPLICAN ST.
TO FILL IN =ROBS BT.LEGAL
/
uDESCRIPTION LOT NO f OWNER
MAIL A�
BLOCK (//f/ TRACT s / wD°PE55
NO. OF SLOGS. � I
SrzE OF LOT NOW ON LOT \�/ CITY TEL. NO.
USE OF �.,] ,. ^ l' 'DISTRICT NO. GROUP MAP PROCESSED BY
.BUILDINGS ��fp�/`!
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ADDRESS09-9 ./�.�4% /// ' CONNECTION DATA
CIT TEL. NO.al—.
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REGISTRATION NO. wF 3OsZ4 COUNTY MANHOLE REFERENCE LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTIO LENGTH FR M }
HOUSE SEWER CONNECTING TO Y.
PUBLIC SEWER @ sS.00 `_ OO - O
P.C.NO.
REPT IC TAN H.SEEPAGE PIT OR V
PITS PN°/OR DPgINFIELD @ 510.00 CO.IMP. NO, _ JOB NO.
1 HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 /t,f `O
I CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIYEIs[x[x RECORD.INSTR.NO. DATE ,
1 WORK TO HOUSE SEWER @ $3.00 IVL
1 OVERFLOWSEEPAGE PIT.GRAINFIELD in
EXTN.,CESSPOOL.DRYWELL.MANH O LES SS.00 y
} ALTER.REPAIR ORABANDONHOUSE HWY.OR ST.WIDENING - Z
SEWER OR DISPOSAL SYSTE M $3.00 STATE ENCROACH M ENT
tI PERMIT NO.
f
INDUSTRIAL
1
WASTE APPROVAL
CHARGES
PEAMTT
�T.r�{OWpN�ERS s z .D
E
e'. AU HORIZATION TOTAL FEE �O CONNECTION CHARGEE
y -%1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON� REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
'.TO THE PUBLIC SEWER. APPROVALS GATE INSPECTOR'S SIGNATURE
Z `SIGNED THIS - 'DAY OF 19_ >
6 OWNER OR NEW HOUSE SEWER
S - OWNERS AGENT_ '.CONNECT ADDITIONAL II
ADDRESS
1 BUILDING OR WORK V
.'SEPTIC TANK,SEEP.PIT(S)
t I HEREBY ACKNOWLEDGE THAT-I HAVE READ THIS APPLICATION` ANO/OR DRAINFIELD
AND-STATE THAT THE ABOVE Is CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
d iPLUMBING AND SEWERS:: "CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 'I AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR,SEWER OR
:LICENSED AS REQUIREY LOS ANGLES COUNTY AND_STAT,E.OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA ON TNAT A THE LEG F ANO INTEND TO DISCONNECT PLUG AND
SEPTIC TANKS
RESIDE IN. THE AB E ESCRI/BED E EN PROPERTY ABANDON HOUSE SEW ER
SIGNATURE J f j' /! BACKFILL ❑.
OF PERMITTEE_ JT SEEP.PIT IS) C3 CESSPOOLS ❑
ALA'TION ROBERT A.
LDWOOD
'c K. �'- M O .' CASH SUPERVISING MECHANICAL ENGINEER
Jfo27 0 9�2 MAR 29 J. 0 0 7.00"
CEBOS 3.62 APPLICATION FOR PERMIT' {�
Teeeaz0 u
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTYENGINEER -•D= --
BUILDING ANDSAFETY VISION
JOHN A'
LAMBLE, County Engineer ADDRESS- /QDI7_= G�
z
0 WILLIAM A. JENSEN, Supt of Building
LOCALITY
H NEAREST
FOR APPLICANT TO FILL.IN `ROSS ST.
LEGAL
DESCRIPTION LOT NO OWNER
/�/} Jn MAIL'
BLOCK li) TRACT O / ADDRESS
NO. OF BLDG5. /yam
SIZE OF LOT I NOW ON LDT ✓ CITY TEL. NO.
O
USE F R7�e�cs�Z__ ^ -
`USE OHCS G`.J DISTRICT'NO: .GROUP MAP PROCE55ED BY
PG
CONTRACTOR ��n
ADDRESS A?-1/ CONNECTION DATA
ATION _ A 1 DEPTH I
'REGISTRATION NO. �O�¢ COUNTTATE Y: MANHOLE REFERENCE 1 J LOWER
q NO. DESCRIPTION OF WORK FEE TYPED CONNE�10 LENGTH FROM
HOUSE SEWER CONNECTING TO TO P.1-
Z PUBLIC.SEWER $5.00 O
S- SEPTIC TANK.SEEPAGE PIT OR JOB NO.
PITS ANO/OR GRAINFIELD $10.00 CO.IMP. NO. yN V
I HOUSE SEWER CONNECTING TO TRUNK PERMIT,NO.= ROAD PERMIT NO:
I PRIVATE DISPOSAL SYSTEM @ $3.00 MY su[x 1,�3/ r
y CONNECT ADDITIONAL BLDG.OR AFFIDAVIT RECORD.INSTR.NO. DATE
.RK TO HOUSE SEWER O $3.00
OVERFLOW SEEPAGE PIT,GRAIN FIELD
E%TN..CESSPOOL.ORYWELL,MANHOLEO $5.00 1 Z
(/3
ALTER.gEPAIR OR ABAN00 A110U5E HWY.OR ST.WIDENING
'y
SEWER OR DISPOSA YS M' O $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL U
- _ -[STC WASTE APPROVAL n
1
OVMER'S PERMIT $ CHARGES
AUTHORIZATION TOTAL FEE - CONNECTION CHARGE FEE
..I HAVE AT THIS DATE A CONTRACT WITH THE,HEREIN NAMED CON REIMBU RSEM ENT FEE
"TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING^DWELLING
TO THE PUBLIC SEWER. - APPROVALS DATE INSPECTOR'S SIGNATURE
,-:SIGNED THIS DAY OF - 19_ - - �,e
^OWNER OR NEW HOUSE SEX / S 'Y
OWNERS AGENT_ ._ CONNECT ADDITIONAL - v +F
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP. PITHS)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND
AGREE TO COMPLY
WITH ALL COUNTY. ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS:. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANG ES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
RE LIFORNIA OR THAT A THE LE R ANO INTEND TO' DISCONNECT PLUG AND
RE.
IDE IN, THE ABS E SCRISE
NTI�gOPERTY. BANOONHOUSE
SEWER
SIGNATURE - BACKFILLSEPTICTANKS ❑
OF PERMRTEE .S EEP,PIT15) ❑ CESSPOOLS ❑
- VALIDATION ROBERT A. WOOD
CK. M CASH SUPERVISING MECHANICAL ENGINEER
: ... O '. _
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