HomeMy Public PortalAbout9509 LA ROSA DR_Sewer__ E-669 I1•D8 E•88
S& APPLICATION FOR PERMIT7"
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL 1
Department of County Engineer
County of LOS'Angeles BUILDING -
JOHN A LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN. SUP'T OF BUILDING LOCALITY �' \✓ O✓C 1�
FOR APPLICANT TO FILL IN CROSS ST. �JU tz,
CC
LEGAL �j
_DESCRIPTION LOT NO.ACf' ' OWNER ^
MAIL
BLOCK TRACT ac• ADDRESS M �� Q'S' t)
NO. OF BLDGS. CITY kkk TEL. NO.
_ n
SIZE OF LOT 19 NOW ON LOT W\ F 5
USE OF DISTRICT N u, MAP
BUILDINGS A-�L� I BK PG
CONTRACTOR T / Q
J CONNECTION DATA -
ADDRESS STATION / �. S
7�a DEPTH
CITY EL. N0. MANHOLE REFERENCE UPPER
❑ STATE v7 cmm-
REGISTRATION N0. //.7
NO. DESCRIPTION OF WORK FEE
TYPE OFTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y, CURB• P.L. M.L. TO P.L.
PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD I C. NO.
EXTN.,CESSPOOL,DRYWELL,MANHOLE Q *$2.00 CO. IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO ?
PRIVATE DISPOSAL SYSTEM Q $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 s 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE `
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE_ INSPEOR-SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING '
TO THE PUBLIC SEWER. - NEW HOUSE SEWER 7
SIGNED THIS,;i!i 310DAYOF 19,5K CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGEN SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPL ATION 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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON CT PLUGHOUSE AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERT 'BACKFILL SEPTIC TANKS C3
SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS
OF PERMITTEE
JOHN A. LAMBIE, COUNTY E (NEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. N.O. CASH
450 .