HomeMy Public PortalAbout10245 LA ROSA DR_Sewer__ L 74650�
768APPLICATION FOR PERMIT
""S42D°`�° COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
LDM
BUILDING AND SAFETY DIVISION ADURESSG OZ S' LjRPROCESSEDBY
IOHN A. LAMBIE, County Enqineer
WILLIAM A. JENSEN, Supt of Building LOCALITY NEAR ST D _
FOR APPLICANT TO FILL IN CROSS sr.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAILADORESSNO.OF SLOGS. IfSIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP LDINGS -C_ T• IK PGCONTRACTOR �— :v JLADDRESS 'y If CONNECTION DCITY TEL.N0. (� 1. STATION DEPTH
STATE MANHOLE REFERENCE
REGISTRATION N0. ✓ ® COUNTY j
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO —p
PUBLIC SEWER @ $3.00 TYPE OF CTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. UR ) P.L. M.L.TO FROM
SEPTIC
PITS AND/OR DRAINFIELD @ 83.00 �.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN..CESSPOOL. DRYWELL @ 52.00
P.C.NO.
HOUSE SEWER CONNECTING TO CO.IMP. NO. JOB NO.
PRIVATE DISPOSAL SYSTEM @ 81.00 0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. U
WORK TO HOUSE SEWER @81.00
SEWER OR DISPOS ABANDON SEHOUSE @ 81.00 STATE ENCROACHMENT 0
PERMIT N0, Q
INDUSTRIAL V
WASTE APPROVAL 0.
CHARGES L0
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE E7
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT,9HLP ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER, 'J {
SIGNED THIS / DAY OF NEW HOUSE SEWER �.L.✓�-a�—
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK.SEEP.PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL Cl DRYWELL ❑
WITH ALL COU TY ORDINANCES AND STATE LAWS REGULATING ALTER.REPAIR.SEWER OR
PLUMBING AN EWERS. SEWAGE DISPOSAL SYSTEM
1 It
ERTIFY THAT I AM PROPERLY REGISTERED AND/OR pISCONNECT PLUG AND
LICENSED A REQUIRED BY LOS ANGELESUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFOR A OR THAT 1 AM TH EG L WNER OF THE ABOVE
DESCRIB D DENTIAL PROP BACKFILL SEPTIC TANKS ❑
SIGNAT SEEP.PITS ❑ CESSPOOLS ❑
OF PE ITTE
®' VALIDATIOKl'\ ROBERT A. WOOD
CX. R.o. CASHH SUPERVISING MECHANICAL ENGINEER
LnCo
0 0 7 0 � JLL 17 1 0 0 5.0 0 n/