HomeMy Public PortalAbout10146 LA ROSA DR_Sewer__ � �
CE8OAPPLICATION FOR PERMIT
"18A042D 2D 11 -
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL 11L111
DEPARTMENT OF COUNTY ENGINEER
_BUILDING AND SAFETY DIVISION FADDRESSING J /
JOHN A' LAMBIE. County Engineer / d
_ WILLIAM A. JENSEN. Supt of.Building L ,
LITY
EST
FOR APPLICANT TO FILL IN !LEGALDESCRIPTION LOT ND.� - R
CLOCK TRACT D - ADDESS.. a .
NO. OF BL GS. ..
SIZE OF LOT NOW ON LOT CITY TEL, NO.
USE OF
BUILDINGS DISTRICT NNO/ GR/{OUP ,e MAP PROCESSED BY
CONTRACTOR K 7 ��
ADDREss 30 /[ ' L ,CONNECTION DATA.
CITY ' TEL. NO.Q/ , '/ 5 ION DEPTH DIY'
SO STATE MANHOLE REFERENCE .p. UPPER
' �
rW
. 1J ❑ COUNTY
PTION OF WORK FEE -TYPE OF CON £ LENGTH FROM l�
ER CONNECTING TO Y. Ap,L. M.L TO P.LER55.00 - P.C.NO.K.SEEPAGE PIT OR CO.IMP: NO. JOB:NO.R DRAIN FIELD • @ s'O.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT N
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLOC.OR AFFIDAVIT AIV SEMS RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ ".00
OVERFLOW SEEPAGE PIT.GRAINFIELD VJ
EXTN_CESSPOOL,DRYWELL,MANHOLE@ 55.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WI IND
BEWE �OR.DISPOSA SYSTEM � $3.00 STATE ENCRO M NT
.PERMIT N.
INDUSTRIAL
WASTE APPROVAL
- - .
OWNERS PERMIT a
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE 1j
I HAVE AT TH15 DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CON N ECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'BSIGNATVRE.
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_
OWNER OR - NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
- BUILDING OR WORK -
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP, PIT(51
AND/ORPftAINFIELD --
AND STATE THAT THE ABOVE IS CORRECT TATE AGREE REGCOMPLY
ULATING WITH ALL COUNTY ORDINANCES AND STATE LAWS REG VLATING
PLUMBING AND SEWERS. CESSPOOL ❑ GRYW ELL ❑
I HEREBY CERTIFY THAT IAN PROPERLY REGISTERED ANO/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM _
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND -
RESIDE IN. THE ABO DESCRIBED RESIDENTIAL PROPERTY ABANDON pON HOUSE G WED
SIGNATURE B ACK FILL S EP TIC TANKS ❑
OF PERMITTEE SEEP,PIT'S) ❑ CESSPOOLS ❑
VALIDATION ROBERTA. wood
M.D'. CASH SUPERVISINGGMEC MECHANICAL ENGINEER
it
824903111-JL4" D' 2 5 ,00- 41
`E°OB °2
D APPLICATION FOR PERMIT
EB
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL'
DEPARTMENT OF COUNTY ENGINEER
BUILDING. AND SAFETY DIVISION BUILDING /
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENBEN. BUp'1 0( Building A
LOCALITY C I
NEAREST
FOR APPLICANT TO FILL IN GROSS ST.
LEGAL
pESCRIPTION LOT NO. / �— OWNER
.•[ MAIL
BLOCK @ TRACT �OA
ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BVILDIS DISTRICT NO. GROUP MAP PR CESSED BY
NG
•�// C BK
CONTRACTO ✓[� ['/ 4/ 'Te•
VYYY V
gpBREss O CONNECTION DATA
ATION EPTH
-
A STATECOUNTY MANHOLE REFERENCE PPER
REGISTRATION NO. C% II �♦ 'mp[RMi
NO. DESCRIPTION OF WOR FEE TTPE OF CONNE T LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CU p M.L.TO P.L.
PUBLIC SEWER SS.00
SEPTIC I.RX.SEEPAGE PIT OR Ol
PITS ANO/OR DRAINFIELD 810.00 CO.IMP. NO. C� JOB NO.
HOU5E SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT
PRIVATE DISPOSAL SYSTEM $3.00
'CONNECT ADDITIONAL BLDG.OR gFFIDAVIT "A "I.1RECORD.INSTq. 10. OATWORK TO HOUSE SEWER ® $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN.,CESSPOOL.ORYWELL.MAN HOLE 0 SS.00ALTER.REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM ® S3.00 STATE ENCIR
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERCHARGESS PERMIT s z o0
CON
AUTHORIZATION NECTION CHARGE FEE TOTAL FEE 1
IHAVE 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 DAT E, INSPECTORS SIGNMTURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER �1
OWNERS AGENT CONNECT ADDITIONAL p Y
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP.FIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAT N FIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY -
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYWELL ❑
IHEREBY 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 I AM THE LEGAL OWNER OF. AND INTEND TO p15CONNECT PLUG PND
RESIDE IN, THE qB DESCRIBED RESIDENT L PRO PE TY. gBgN OON HOUSE SEWER
SIGNATURE BACKFILLS-TICTANKS ❑
OF PERMITTEE SEEP.PIT(5) ❑ CESSPOOLS
VALIDATION ROBERT A. WOOD
M.0. CASH SUPERVISING MECHANICAL ENGINEER
L ,� 8 2 4 C v JUIL 31 1 0 D 7�0 .. _