HomeMy Public PortalAbout10232 LA ROSA DR_Sewer__ ;.6&E';,I2-„A APPLICATION" FOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles AODREssG 2
WM. J. FOX, COUNTY ENGINEER
CASSATT D. GRIFFIN. 6uP•T oP BUILaING LOCALITY e '>rL�'�� _
FOR APPLICANT TO FILL IN NEAREST o� 7 • r
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LEGAL
DESCRIPTION LOT N0. /v
OWNER 60a,, C? C �lA�
BLOCK TRACT f J S3 / ADDRESS 1 0 2 "' Z I
SIZE OF LOT70]4' /60 NOWOONBLOTS
` f— CITY Y7• 'Z- • TEL. N 6.
USE OF /J/
BUILDINGS �iAT� �';/�/2'���- DISTRICT NO. GROUP MAP
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CONTRACTOR �� � (�jl
ADDRESS _yC C[O�NNECTION DATA
CITY, al , p//I�EL. NNO.0 7 ]/ STATION '� J D ❑EPTH
REGISTRATION N0. � n�-- (.J .J ` -�COUNTY STATE -/ MA UPPENHLR REFERENCE LOWER
TYPECURB ECTION LENGTH FPM
NO. DESCRIPTION OF WORK FEE Y. P.L. O
M.L.TO P.L.
LHOUSE SEWER CONNECTING TO a
PUBLIC SEWER Q $ 3.50
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00 _
CONNECT ADDITIONAL BLDG. OR CO. IMP. N0. /3Z JOB. N0.
_ WORK TO HOUSE SEWER 1.00 _
ALTER OR REPAIR EXISTING ''7^� /
_
-SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO3
,DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM . 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
,CESSPOOL- DRYWELL —— WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 DD
AUTHORIZATION TOTAL FEE' s—(5 REIMBURSEMENT FEE
I HAVE-THIS .DATE CONTRACTED WITH .THE HEREIN NAMED CON.
' TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER . /
NEW HOUSE SEWER
SIGNED THIS Y OF �� •.19r �
OWNER- OR CONNECT-ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS L.01_" L 2, SEPTIC TANK,SEEP..PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL[3DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR '
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 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 RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS 11
SEEP.PITS) ❑ CESSPOOLS
SIGNATURE
OF PERMITTEE .Fr / }�� ro
WILLIAM J. FOX. COUNTY ENGINEER VALIDATTIJ"Ok ,(�A//11 4 B'
-BY _ I_ACO 5 0 4 Irr°, APR 12 4 4.5 O in
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