HomeMy Public PortalAbout10240 LA ROSA DR_Sewer__ J - APPLICATION FOR PERMIT
5&E66DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL 1
Department of County Engineer
County of Los Angeles AD RESS' Q _
JOHN A. LAMBIE. COUNTY ENGINEER /y�
® CASSATT O.GRIFFIN, SUPT of BUILDIN. LOCALITY oc� i7V
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL / OWNER
DESCRIPTION LOT N0. �/ /� �•
MA L
BLOCK TRACT'
3/ ADDRESS_�O�(
NO. OF BLOGS. CITY C TEL: N0.
SIZE OF LOT X
BUIOF LDINGS NOW ON LOT LDINGS � •R - A. 4,d DISTRICT NO. GROUP MAP
PG
CONTRACTOR E7T T BL_ y`
ADDRESS K CONNECTION DATA
STATION DEPTH
CITY 464OTEL. N0. ANHOLE REFERENCE
TATE WER
REGISTRATION NO. Q,,/z ❑ COUNTY O /
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF C�[lNECTION LENGTH FRO
PUBLIC SEWER @ $3.50
Y, CUR P.L. M.L.TO P.
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR,DRAINFIELD @ $3.00 _
OVERFLOW SEEPAGE PIT,DRAINFIELD C •
EXTN.,CESSPOOL,DRYWELL,M AN HOLE @ $ 2.00 CO. IMP. NO. b O.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD P IIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ S 1.00 QO PERMIT NO.
ALTER.REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ S 1.00 WASTE APPROVA
CHARGES
CONN ION CHARGE FEE
OWNER'S PERMIT S t 00
AUTHORIZATION TOTAL FEE / / MBURSE AIENT FEE
VON APPROVALS DATE INSPECTORS SIGNATUR
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEW E-gJ NEW HOUSE SEWER "
SIGNED THISDAY OF AuL 19� CONNECT ADDITIONAL
OWNER OR / BUILDING OR WORK
�MeR6 1 ENT10A SEPTIC TANK,SEEP, PIT($)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AB REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL. OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PR TY. BACKFILL SEPTIC TANKS❑
SIGNATURE
SEEP. PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSF,
CK. S.
Lo' 2 0 �5" AOS 1 j. 4 2..0_0 In
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