HomeMy Public PortalAbout10129 LA ROSA DR_Sewer__ v
CESOB 3-E2 .APPLICATION FOR PERMIV
JSAEA30
COUNTY OF LOS ANGELES .SEWER-SEWAGE DISPOSAL
DEPARTMENT OF-COUNTY.'ENGINEER_ .
BUILDING AND SAFETY DIVISION BUIL NG, r: .
JOHN A: LAMBIE. County Engineer ADDRess0 �
WILLIAM A. JENSEN,.Supt of Building
LOCALITY
FOR APPLICANT TO FILL IN CRO5555T' J
LEGAL
DESCRIPTION LOT NO. ' OWNER ,
BLOCK al TRACT /
ADDRESS
NO, OF BLDGS.
S12E OF LOT NOW ON LOT \ CITY TEL, NO.
USE OF o
r BUfLDINGS A7"z':v0re4&G ////1 DISTRICT NO.GROUP �K MAP PROCESSED BY
CONTRACTOR �VI r ��? / Z/
ADDRESS :�04c� i -I- _� _ !I 2 �rONNECTION DATA
CITY /�. �`� EL. NO. /p (/� � �N'
G5 TION DEPTH
STATE MANHOLE REFERENCE'
REGISTRATION NO. �8 Ai"""r ❑ COUNTY ,LO ER
ANO. DESCRIPTION OF WORK FEE TYPE OF CONNE ON LENGTH FROM }
HOUSE SEWER CONNECTING TO Y, P.L. M.L.TO P.L. O
PUBLIC SEWER 55.00
P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS ANO/OR.GRAINFIELD @ 510.00 CO.IMP. NO. K/ LY/ JOB NO..
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® E3.00 TRUNK PERMIT NO. ROAD PERMIT NO.�
CONNECT ADDITIONAL BLDG,OR AFFID47VO. [s[x[ RE
MCORD INSTR,NO. DATE
WORK TO HOUSE SEWER If $3.00
OVERFLOW 5EEPAGE PIT.DRAINFIELD
EXTN.,CESSPOOL.DRYWELL MAN H O LE to 55.00 y
ALTER.REPAIR OR ABANDON HOUSE HWT.OR ST.WIDENING Z
SEWER OR D I.P.SAL SYSTEM ® S3.00 STATE ENCROACHMENT
y r PERMIT NO.
Y INDUSTRIAL
JWASTE APPROVAL
CHARGES
q
OWNER'S PERMIT 3 zA
AUTHORIZATION TOTAL FEE CONNECTION CHPRGE FEE
I HAVE AT THIS OATS A CONTRACT WITH THE:HEREIN NAMEDREIMBURSEMENT FEE
.TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING p 1 p
S
TO THE PUBLIC SEWER. APPROVALDATE INSPECTOR'S SIGNATURE
f SIGNED THIS DAY OF _ "" 19_ 't
OWNER OR NEW HOUSE SEWER •'T'S'G
y OWNERS AGENT - CONNECT ADDITIONAL U /
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SFIELD T151
I
HEREBY ACKNOWLEDGE THAT 1 'RR C`READ GRE ATO CO T10N AND/OR DRAINFIELO
AND STATE THAT THE ABOVE 15 CORRECT ANO AGREE E COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LBWS REGULATING.
PLUMBING AND SEWERS: CESSPOOL ❑ ORYWELL:❑
HEPEBV CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
it LICENSED.AS. REOUIREO BY LOS ANGLES•COUNTY ANO STATE OF SEWAGE DISPOSAL SYSTEM
.
CALIFORNIA OR THAT THE LEGAL O AN
INTEND TO CIDISCONNECT PLUG AND
RESIDE N. THE 4B0 O BCRIBED TIR ,ROPERTY.
V BANDON HOUSE SEWER
SIGNATURE /J�� BA CKFILL SEPTIC TANKS ❑
J OF PERMITTEE L, _ 'BEEP;PIT(S) ❑ CESSPOOLS ❑
P VALIDATION ROBERT A. WOOD
CK." M.O. CASH "SUPERVISING.MECHANICAL ENGINEER.
r 2 7 1 1 t2 MAR 2 9 1 0 D 7,0 0- v
CEROB
76A8G2D 362 APPLICATION FOR PERMIT
-
_ COUNTY OF LOS ANCELaS SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUIL'DI'NG AND SAFETY DIVISION BUILDING - -
JOHN,A. LAMBIE. County Engineer ADDRESS,
WILLIAM'A JENSEN, Supt o1 Budding
_t
LOCALITY
NEAREST
! FOR APPLICANT TO FII.L IN `RG55 ST.
LEGAL
DESCRIPTION LOT NO. �� OWNER azay G'
MAIL '
BLOCK TRACT 0� -/ .ADDRESS
=1%
O. % BLOGS. _
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDI NGB DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTORS 7--3 � ell
ADDRESS [L��pgLLLL" «<G.I//i�s�,. "CONNECTI N DATA a
EL. NO /ij/ %/J ST ION DEPTH
TATE MA NHO LE REFERENCE
REGISTfl ATION NO. `�'F"/ COUNTY � LOWER
NO, DESCRIPTION OF WORK FEE TYPE OF cox c LNO.ENCTH— I
HOUSE SEWER CONNECTING TO Y. P L. M.L.TO P.L.
PUBLIC SEWER @ 55.00 P.C. O
SEPT
ICTAN K.SEEPAGE PIT OR
PIT$AND�OR DRAIN FIELD @ SIO.00 CO.IMP.NO. JOB NO. V
HOUSESEWERCON N ECTINGTO TRUNK PERMIT NO. ROAD.PERMIT NO. ,(p7
' PRIVATE DISPOSAL SYSTEM @ S3.00
CONNECT ADDITIONAL B DG.OR AFFIDAVIT .[Iv z[n[ RECORD.INSTR.NO. DATE
E WORK TO"USE SEWER @ 53.00
OVERFLOW SEEPAGE PIT,GRAINFIELD
C EXTN CESSPOOL.DRYWELL.MANHOLE@ $5.00
ALTER.REPAIR OR wBANOON N S / HWY.OR ST.WIDENING
1 SEWER OR DISPOSAL SY EM @ $3.00 STATE ENCROACHMENT
I{ PERMIT NO.
INDUSTRIAL
1 i = WASTE APPROVAL
CHARGES
OWNERS � PERMIT s -
S CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE � -
' I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
41 ('TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
} , TO THE PUBLIC SEWER, APPROVALS DATE INSPECTOR'S SIGNATURE
(,SIGNED THIS DAY OF 19_ - q
OWNER OR NEW HOUZW ERI
OWNERS AGENT >✓
-CONNECT ADDITIONAL O
F .ADDRESS BUILDING OR WORK
S
EPTIC TANK FIE(PIT($)
I HEREBY ACKNOWLEDGE THAT ( HAVE READ THIS APPLICATIONR GRAINFIELD
F •.AND. STATE THAT THE RIMA IS CORRECT AND.AGREE E COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS. REGULATING
j .PlU MOING AND SEWERS. OOL ❑ pRYW ELL Cl
1 HEREBY CERTIFY THAT 1 AM PROPERLY. REGISTERED AND/OR REPAIR,SEWER OR
LICENSED AS REQUIRE Y LOS ANGLES COUNTY AND STATE OFGE DISPOSAL SYSTEM
CALIFORNIA OR THAT AM THE'LEGAC -OF ANO INTEND TONNECT PLUG AND
4 RESIDE IN THE AB E D SCRIBE ENT "PROPERTY
HOVSESEWER
ILL SEPTIC TANKS.❑PIPISI ❑ CESSPOOLS ❑
t
VALIDATION ROBERT A. ,WOOD
. cKM o CASH SUPERVISING MECHANICAL ENGINEER
2712ty RAP 2911 D 2500 n