HomeMy Public PortalAbout9249 LA ROSA DR_Sewer__ r
CE80810163 V, APPLICATION FOR PER
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL �1J'
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONBUILDING
y Engineer JOHN A. LAMBIE, Count n ADORE
ss
WILLIAM A. JENSEN, Sup't o4 Building
L OCALiTY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF-BLDGS Cr"
SIZE OF LOT NOW ON LOT CITYTE JNO.
USE OF
BUILDINGS DISTRICT NO ROUP AP PROCES BY
B PG
CONTRACTOR
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ADDRESS l' / / CONNECTION DATA
CITY___f-' V"- % 'j.__ZTEL NO is b. STATION / D DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO /"�% COUNTY LOWER
NO DESCRIPTION OF WORK FEE TYPE C NLENG,
HOUSE SEWER CONNECTING TO UR r M L P a
PUBLIC SEWER @ $5 00
SEPTIC TANK,SEEPAGE PIT OR - P C NO. O
PITS AND/OR DRAINFIELD @ $1000 CO IMP. NO. JOB NO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ S300 ^
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN,CESSPOOL,DRYWELL,MAN HOLE @ $5 00
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING N
SEWER OR DISP SAL SY EM $300 STATE ENCROACHMENT z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s 2 00
AUTHORIZATION TOTAL FEE 1 CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT l
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S) Y L
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS,APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTYORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE VE D RIBED RESIDENTIA L�PRO E T ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP.PIT(S)
❑ CESSPOOLS ❑
( LIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M O CASH
Lr't1 6 4 3 7 1,0, AUG 5 1 0 D 5 .0 0-