HomeMy Public PortalAbout10143 LA ROSA DR_Sewer__ "AS'°D
ceeoa.e.ee APPLICATION FOR PERMIT 1
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRESSG D S
TORN A. LAMBTE, County Engin.:
CASSATT D. GRIFFIN, Supt of Building LOCALITY
AR
NEEST
FOR APPL;qANT.W FILL 1pCROSS ST. T Jy C r
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAIL
ADDRESS
O.OF BLD S.
SIZE OF LOT NOW ON LOT CITY TEL.NO.
USE OF
BUILDINGS DISTRICT O. GR_0P BK MAP PG Ppf�E55E
CONTRACTOR At r � ff /y ' t-,
(IPr.
ADDRESS T OI • v ,t.Q.vPI n-- CONNECTION ATA
TEL. NO. e /Q3 STATIDN DEPTH
�'C• BSTATE MANHOLE REFERENCE UPPER
REGISTRATION NO. COUNTY li LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER 0 $3.00
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTIONLENGTH F OM
PITS AND/OR DRAINFIELD 0 $3.00 Y. CU B P.L .L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAIN
EXTN.,CESSPOOL,DRYWELLMANFIELFIELD $R.00
HOUSE SEWER CONNECTING TO P.C.N0.
PRIVATE DISPOSAL SYSTEM @ SI.00 CO.FMPVNO. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0.
WORK TO HOUSE SEWER @ $1.00 PJ
SEWER OE PAIRO R ABANDON HOUSE ® SI.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PST S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE & Oy REIMBURSEMENT FEE
I LS HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVADATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF Ig_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL: p�
OWNERS AGENT � BUILDING OR WORK
T�
ADDRESS SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYINELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTI P PERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE
SEEP. PITS CESSPOOLS❑
OF PER MITTE
®P �7AI.IDATIQPI RA.WOOD
SUPERVISING
NG MrC MGCHANIGAL ENGINEER
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