HomeMy Public PortalAbout9301 LA ROSA DR_Sewer__ 6G 12-54 APP�.�S�CATION FOR.. PERMIT 1
DIVISION OF BUILDING AND.SPiFE�Y SEWER-SEWAGE DISPOSAL
Depm-invent of County Engin6:er j
County of Los Angeles aUILDING
WM.J. FOX, COUNTY ENGINE'R ADDRESS
CASSATT-DoGiRIFFIN, SUP`T•oF'BUILDING �.• - `LOCALITY 1"
FOR APPLICANT TO FILL IN caoss T:IGAL
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"•,CRIPTION LOT N0, OWNER ��f /J'l�-�G4� jasl
moi•• TRACT f C'! MAIL- °I ' i
ADDRESS
NO.OF BLDGS. �:,a ✓k..n'x t- a.•. ..x"•.„„s,. ..^^✓z.,. - ., I
IE';OF LOT NOW ON LOT CITY TEL. NO.
SE OF -
"dUILDINGS r Z' ' DISTRICTN0. _ GROUP., MAP
....r T
.. CONT''RACTOR �./�C��J/YCj�IJ�'/ �-Y�[a�” G•,i�. _.... .._.. ., -.. BK kfy
ADDREss ;U 3 hj/,v, e&2d CONNECTION DATA
jY+ �e TEL. NO. '71,1CJ_ SFTATION `6 20 DEPTH 7 +.-
,� AM STATE ,,..r MANHOLE REFERENCE `....
REGISTRATION NO. 1 G� , {i`7�(� ❑ COUNTY UPPER LOWER
rr TY F CONNECTION LENGTH.;FROM. -ra J
NO.R�' DESCRIPTION OF WORK FEE R. CURB P.L. M.L.TO P.L.'HOUSE SEWER c�
+I �•
PUBLIC SEVER CONNECTING 70 @ $,,3.50 _ ,ya
HOUSE SEWER CONNECTING TO
H,PRIVATE DISPOSAL SYSTEM 1.00 CONNECT V_ ��f 1
`WORK TO HOUSE SEWER NAL CDG. OR 5.00 ® 7/ I JOB. NO.
ALTER OR REPAIR EXISTING
ti SEVER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.x. ,4,z
s DISCONNECT AND ABANDON SEWER_ISTATE ENCROACHMENT
1 P,iiDiOR DISPOSAL SYSTEM 5.00 PERMIT NO.
YSEPTIC TANK, SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
"CESSPOOL-DRYWELL WASTE APPROVAL �`"'- ----�-►. Ii
j SPECIAL CONDITIONS ONLY" 2.00 CHARGES
s - CONNECTION CHARGE FEE
f OWIBER'S -S00
1 AUTI'IORILATION'] ' PERMIT
TOTAL FEE-> - _ ,REIMBURSEMENT FEE
1 HAVE._THIS..DATE CONTRACTED WITH THE HEREIN'NAMED,CON• 1
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
APPROVALS"' ~'DATE INSPECTOR,SSIGNATURE
TO THE PUBLIC SSWER
SIGNED THIS '`` DAY OF-�&� 19---,) -NEW-HOUSE sEwER
OWNER- OR -- -- - CONNECTADDITIONAL --- - - -
OWNERS AGENT BUILDING OR WORK
.. .....,. _. ._ SEPTICTANK,.SEEP,..PIT(S) --
AND/OR DRAINFIELD
I
- \1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
`0"STATE-THAT-THE•ABOVE IS CORRECT-AND AGREE'TO-COMPLY
Y AI.'_ COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
11-'ING AND SEWERS; _ _. ..SEWAGE DISPOSAL.SYSTEM. -- -- _ -- _- `
.-HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR �
"LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND - -�
CALIFORNIA OR THAT I AMS THE-LEGAL- OWNER OF-THE 'ABOVE- ABANDON HOUSE..SEWER -
DESCRIBED RESIDENTIAL PROP TY. . BACKFILL SEPTIC TANKS❑
_... .��. �C��f► _. -.SEEP. PITS) ❑_CESSPOOLS 0:
SIGNATURE !U/
01 PERMITTEE,'
WILLIAM J.-FOX.-COUNTY ENGINE VAIMATIOId_ o, .. , ..
BY BY
DEPUTY �� J o�."/�Lw�r/�_/ DEPUTY �
BY [.//_`
DEPUTY IIFPUTY