HomeMy Public PortalAbout9406 LA ROSA DR_Sewer__ .86608 tt_s� APPLICATION FOR PERMIT
7
ceeoe COUNTY OF LOS ANGELES .8.
SEVO/ER-$EW/4GE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LABIE, County Engineer ADDRESS
CINASSATT D. GRIFFIN, Supt of Building
LOCALITY
[7DESCRIPTION
OR PPLI T IN NEAREST.
LO 0. OWNER
TRACT MAIL
� ADDRESS v
N0.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY - , EL.N0.
USE OF
BUILDINGS - ) DISTRICT NO. I GROUP MAP
CONTRACTOR _<5I / BK PG/
ADDRESS Cjj / CONNECTION DATA O/mss &
CITY �' EL.NO. STATION DEPTH
9P�STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. ❑ COUNTY LOWER
NO. DES CRIP IOT N OF WORK FEE a
HOUSE SEWER CONNECTING TO C � 1
PUBLIC SEWER @ $3.%T SEPTIC TANK,SEEPAGE PIT OR TYPE OF CO NECTION LENGTH FROM
ITS AND/OR DRAINFIELD @ $3.00 Y. CURB P.L. .N TO P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P. C. N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. NO. OB NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT ROAD PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $1.00 STATE ENCROACHMENT
PERMIT NO.
✓' -� % INDUSTRIAL
WASTE APPROVAL
CHARGES
OVMER'S PERMIT S 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE , 0 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINGAMED DWELLIING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLICS E
SIGNED THIS DAY OF fr 149 NEW HOUSE SEWER
OWNER ORA e CONNECT ADDITIONAL r J !
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP, PIT(S) L'
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. -
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM -
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTI/y_Q, PR ERT Y. BACKFILL SEPTIC TANKS ❑
SIGNATURE /�'J� SEEP. PIT(S) ❑ CESSPOOLS ❑
OF PERMIT!
OF - ALIDATION ROBERT A. WOOD
cK. M.O. CASH SUPERVISING MECHANICAL ENGINEER