HomeMy Public PortalAbout10231 LA ROSA DR_Sewer__ '°A"AE° APPLICATI0 FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADORE ASS
DDRE
])O IN A. MB
LAIE. Ceunty En par
CASSATT D. GRIFFIN. Supt of Building LOCALI
FOR APPLICANT TO FELL IN NEAREST
CROSS ST.
LEGA'
LOT NO. OWN
BLOCK TRACT MAIL
ADDRESS
�Y NO.OF SLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
DI t DISTRICT NO. GROUP MAP P CESSED BY
BK PG
BUILDINGS --Q [,/R/p
CONTRACTOR .Q � �I /�� 12,,
Y' L0. t
ADDRESS - CONNECTION DATA -
C Y lSTATION
DEPTH -
�STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. O� �� ❑ COUNTY OWER
NO. DESCRIPTION F ORK FEE - - _
HOUSE SEWER CONNECTING TO r
PUBLIC SEWER @ $3.00 TYPE 0 TION LENGTH FROM J
PITS AND/OR DRAENFIELDIT OR @ S3.00 Y. CURB
SEPTIC gP.L.
M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL. DRYWE LL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO. -
PRIVATE DISPOSAL SYSTEM @ $1.00 co-imp-No JOB NO.
WORK TOi HOUSE SEWER LOG.OR @ S1.00 TRUNK PERMIT NO. ROAD PERMIT NO. eT
ALTER,
OF Dp5P09RL SYSTOEM HOUSE @ $I 00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION_C HARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR.S'SIGNATURE
TO THE PUBLIC S WE$„ �y / ,
SIGNED THIS DAY OFJP,rQ�19iL NEW HOUSE SEWER
OWNER OR / CONNECT ADDITIONAL
OWNERS AGEN " BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSED
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
ER
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS Ll
GNATURE
SEEP.PITIS [ICESSP00 S ❑
OF PERMITTE �
®r VALIDATION . ROBERT A. WOOD
QA. M.0. Q M SUPEA
SUPERVISING MECHANICAL ENGINEER
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