HomeMy Public PortalAbout9435 LA ROSA DR_Sewer__ 8&F-66 11.55 APPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Depo=tment of County Engineer
- + County-of Los Angeles BUILDI�� CADDRESJOHN A. LAMBIE. COUNTY ENGINEER —CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALI
FOR APPLICANT TO FILL IN
NEAREST. -'
LEGAL OWNER
DESCRIPTION LOT N0.
BLOCK TRACT- l 3 O - MAIL
ADDRESS /�A
^ NO. OF BLDGS. -
SIZE OF LOT U NOW ON LOT CITY TEL. N0.
USE OF ✓ DISTRICT NO. GROUP MAP
BUILDINGS
PG
CONTRACTOR �K
ADDRESS 8 •� � Z CONNECTION DATA
r
/D STATION - DEPTH
CITY TEL. NO. ,.,/ MANHOLE REFERENCE UPPER
y ep?ll STATE OW
REGISTRATION NO. ❑ COUNTY ,
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO Y. RB P.L. M.L.TYPE OF CTION LENGTH FROM
TO P.L.
PUBLIC SEWER @ $3.50 , 97
SEPTIC TANK,SEEPAGE PIT OR '
PITS AND/OR DRAINFIELD Q $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. NO.
EXTN.,CESSPOOL,DRYWELL,MANHOLE Q $2.00 CO. IMP. NO. 10B NO.
CONNECTINGHOUSE SEWER TO
PRIVATE DISPOSAL SYSTEMQ $1 00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT '
WORK TO HOUSE SEWER Q $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE '
OWNER'S PERMIT $ 1 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE ?3.
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON. APPROVALS DATE INS ECTOR'SSIGNATURE
TRACTOR-TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS �' DAY OF A�^-� 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD -
1 HEREBY ACKNOWLEDGE THAT I 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
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL_- OWNER OF THE ABOVE
DESCRIBED RESIDENT PROPERTY. BACKFILL SEPTIC TANKS❑ �t1
SIGNATURE C SEEP. PIT(S) ❑ CESSPOOLS L
OF PERMITTEE
ce-
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATIO ROBERT A.WOOD, CHIEF PLBG. INSPECTOR
Cl(. M. O.
7;2_TR�` AN 28."_ 4 A 4.50 M
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