HomeMy Public PortalAbout10135 LA ROSA DR_Sewer__ DEBDB B-B2 APPLICATION O ERMIT�
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL Iu1
DEPARTMENT OF COUNTY ENGINEER ,
BUILDING AND SAFETY DIVISION BUILDING ,.
JOHN A, LAMBIE, County Engineer ADDRESS��� J 1
WILLIAM A. JENSEN. Supt o1.Building /
1 LOCALITY 41
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL q I
DESCRIPTION LOT NO y OWNER
MAIL
BLOCK TRACT - ADDRESS
NO. OF.BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
BK
CONTRACTOR
ADDRESS �� i/L2� CONNECTION DATA L
If
EL NO.
5 TION DEPTH
CITY -¢ /�
TATE MANHOLE
REGISTRATION NO. �f.. ❑ COUNTY �Cr-i'{• LOWER
NO. DESCRIPTION OF WORK FEE TY EOF CO NE N I ' LENGTH FROM
HOUSE SEWER CONNECTING TO Y. a P.L. M.L.TO P.L.
PV ELIC SEW ER @ 55,00 O
SEPTIC TgNK,SEEPAGE PIT OR PC No
NO.
PITS qN°/OR DRAINFIELD SIO,00 CO.IMP.NO. ( VOR NO, /l�11//y ))) u
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. 7^ /
PRIVATE DISPOSAL SYSTEM S300 i L
CONNECT ADDITIONAL SLUG.OR gFFIOAVIT WFIY ESF flECORD.INSTR.NO. DATE
WORK TO H OUSE SEWER 5N.00
OVERFLOW SEEPAGE PIT.DRAINFIELD ,1
E%TN.,CESSPOOL,DRYWELL,MANHOLE S500
ALTER.REPAIR OR ABANDON HOU5E HWY. OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM S3.°O STATE ENCROACH MENT
PEFMIT NO.
INDUSTRIAL
WASTE APPROVAL AI
OWNERS PERMIT 4 CHANGES z oo t -
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE17 7 449
I HAVE AT THIS DATE A CONTRACT WITH THE HEREI NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED E%ISTING OW FEEING APPROVALS DATE INSPECTOR'S SIG NATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF-19—
OWNER
F19_OWNER OR NEW HOUSE SEWER v_r'G'S
OWNERS AGENT_
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION Ary°/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT AM THE LEG L OW R OF. AN. INTEND TO DISCONNECT PLUG AM-
E
IN. TME AB E DESCRIB R ENT A PROPERTY. US
ABANDON HOE SEW C
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMRTE
SEEP.PIT(51 ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK! M.O. CASH
Li�vO 2 7 1 4'w^ i i;iR 2 ). 0 D
CEBDB3.°= APPLICATIQN FOR PERMIT
TeA5a2D COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
BUILDING AND SAFETY DIVISION BUILDING O� ✓��
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Supt of Building /�
LOCALITY
NEAREST
FOR APPLICANT IIZIN
/TO FP CROSS50
5T.
DESCRIPTION LOT NO. r / - `� OWNER
/f ^ MAIL
BLOCK TRACT �v ADDRESS
NO. OF BLOGS.
SIZE OF LOT NOW ON LOT EITY TEL. NO.
USE OF
BUILDINGS �lGfG�lj/?� DISTRICT NO. GROUP "Al PROCESSED BY
OK PG
CONTR4CTOfl '
AD�DREsstj`U�9/ ��j -+ CONNECTI NDATA t
CITY /Gj ,e �d,�(,TE/L. NO. ` S TION DEPTH
REGISTRATION T NO. �iV ¢LY COUNTY MANHOLE REFERENCE ,/i LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTIO LENGTH FROM �.
OUSE SEWER CONNECTING TO CU .L. M.L.TO P.L. O
ELIC SEWER Q 5SOo
SEPTIC TANK,SEEPAGE PIT OR /7 I J00 NO. V
PITS ANO/OR DRAINFIELO 0 510.00 CO.I.P. NO. 1 4
NO U SE SEWER CONNECTING TO / O
PRIATE DISPOSAL SYSTEM S3.00 TRUNK PERMIT NO. ROAD PERMIT NO.
V
CONNECT ADDITIONAL SLOG.OR AFFIDAVITMry
Y IAIIMI"i RECORD.INSTR.NO. DA E
WORK TO HOUSE SEWER ® SSOO K
OVERFLOW SEEPAGE PIT,GRAINFIELD T
EXTN..CES5POOL.DRYWELL.MANH 0 $5,00 �yf
ALTER.REPAIR OR ABANDON HWY.OR ST.WIDENING
SEWER OR DISPOSAL 5 FTE 0 53.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER, DATE INSPECTOR
'B SIGNATURE
SIGNED THIS DAY OF 19_ I'
OWNER OR NEW NOII� _R4•
OWNERS AGENT CONNECT ADDITIONAL A
BUILDING OR WORK `
ADDRESS
SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS, CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLE O Y AND STATE OF SEWAGE D15POSAL SYSTEM
CALIFORNIA OR THA M THE LEGAL HER O AND INTEND TO DISCONNECT PLUG ANO
RESIOE IN, THE A E ESIRIB R NTIq OPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTE ❑
SEEP, IT(S1 ElCESSPOOLS
CN.
0M.O. CASH VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
LAW 27133 I;,R2911 D 251- 0"
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