HomeMy Public PortalAbout10140 LA ROSA DR_Sewer__ I0.62
75AG42D APPLICATION. FOR PERMIT �J�I
TBA 04 s II
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL Iu'
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION .."DING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN. Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
EGAD
DESCRIPTION LOT NO
OWNER
MAIL
BLOCK TRACT / O ADDRESS
NO, OF SLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS pISTRI7�F. UP MAP PROCESSED BY
CONTRACTOR TY �BK � PGADDRESS_ ICONNECTION DATA L/1.
STATION L DEPTH
CITY TEL. NO, /(J�d
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. GGLINTY 1�041GR�
NO. DESCRIPTION OF WORK EE
TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO it Y. _ P_L. M.L.TO P.L.
PUBLIC SEWER 55.00
SEPTIC TANK.SEEPAGE PIT OR P.C.NO. V
CO.IMP.NO. JOB NO.
PIT.AND/OR GRAINFIELD 510.00 I
�HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO�PRIVATE DISPOSAL SYSTEM 53.00CONNECT A OUSE SEW BLDG.OR AFFIDAVIT ery s[K[ RECORp. INSTR.NO. PATE
WORKTO HOUSESEWER 43.00OVERFLOW SEEPAGE PIT.GRAINFIELD
EXTN..CESSPOOL.DRYWELL.MANHOLE @ 55.00 HWY.OR ST.WIDENING
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ 53.00 STATE ENCROACHMENT
PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
OWNER'S IT
CHARGES
s z o0
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FE£
ITHAVE ATHIS DATE A CONTRACT WITH THE HEREIN NAME. CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER, APPROVALS DATE' INSPECTOR'S S IG�trjyRF
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL P• r „y
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(5)
HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION qN./OR DRgINFIELD
AND STATE THAT THEORDINANCES
ABOVE IE CORRECT AND AGREE E COMPLY
WITH ALL COUNTY ORDINANCE. ANO .TATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ .RYW ELL ❑
I HEREBY CERTIFY THAT 1 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 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THEAB E DESCRIBED REST IAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF pEflMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑
CVALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
f
1_t,W � " h 21 JUL 31. _ c o 7.G 0