HomeMy Public PortalAbout10214 LA ROSA DR_Sewer__ � .
• G�.44650 INSERTS .
.CEa°aAPPLI ATION FOR PERMIT
TaneazD COUNTY OF LOS ANGELES
SEWER-SEWAGE .DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
-
BUILDING AND SAFETY DIVISION BUILDING
UILDIN
jGRN A. DRESS
IAMBIE, C°vaty E. 0r
WRSRiM A. JENSEN. Supt o1 P2,inq .LOCALITY
NEAREST (7�
FOR APPLICANT TO FILL. IN CROSS sr. J/
LEGALOWNER...
C75L
DESCRIPTION LOT N0.
BLOCK TRACT aa MAIL E
V ADDRESS J C,
NO.OF SLUGS.
SIZE OF LOT NOW ON LO CITY TEL. N0USDF .
BUELDINGS D'[STRICT NO. GROUP) BK P6_ MAP - OCESSED BY
�r I
CONTRACTOR / I -
ADDRESS .-[- CONNECTION DATA
CITY 56, TEL.NO. STATION DEPTH
STATE ;MANHOLE REFERENCE UPPER
REGISTRATION NO. a COUNTY LOWER
No. DESCRIPTIO OF WO K EE
HOUSE SEWER CONNECTING TO i(wr O uP
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROSEPTIC TANK.SEPAGE
_
PITS AND/OR DRAENFIIELD1T OR @ $3.00 Y. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT. DRAINFIELD
EXTN..CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.CO. JOB NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 N0. S.
CON / G--0NECT ADDITIONAL BLDG,OR Q TRUNK PERMIT NO. ROAD PERMIT NO. V
@
WORK TO HOUSE SEWER $1.00
ALTER. REPAIR O R ABANDON SYSTEM HOUSE @ $t 00 STATE ENCROACHMENT -
SEWERPERMIT NO. O
N
INDUSTRIAL U
.. _ -WASTE APPROVAL w
.CHARGES a
OVVNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE -
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
1 HAPPROVALS DATE INSPECTOR'S SIGNATURE
AVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- _ _
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS - - DAY OF 19_ NEW HOUSE SEWER
OWNER OR ,,'' CONNECT ADDITIO - )
OWNERS AGENT��-v .:BUILDING OR WO
RNAL
K--
ADDRESS SEPTIC TANK,SEEP. PIT($)
AND/OR DRAINFIELD _
I HEREBY ACKNOWLEDGE THAT I HAVE READ-THIS APPLICATION - --- - - -- -
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ _
WITH ALL COU ORDINANCES AND STATE LAWS REGULATING _ALTER,REPAIR,.SEWER OR
PLUMBING ANp WERS: SEWAGE DISPOSAL SYSTEM
I HEREBY RTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED A OUIRED BY LOS A LES COUNT AND STATE OF ABANDON'HOUSE SEWER
CALIFORN THAT I AM THE AL OWN Q�-THE ABOVE
DESCRIB E D NTIAL PROPERTY /J BACKFILL SEPTIC TANK$ ❑
SEEP. PIT($) ❑ CESSPOOLS ❑
SIGNAT R [r1
OF P R TE
®r VALIDATIOKJ — 1 ROBERT A. WOOD
CK: M.o.. asN/J SUPERVISING MECHANICAL.ENGINEER -
f -� 3 .0 0 GL v