HomeMy Public PortalAbout9512 LA ROSA DR_Sewer__ Or 66,2-sa APPL,I�CATI�ON.IFO.R ,P•E RM IT 1
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL.
Department of County Engineer
County of Los Angeles BUILDING �Q ^ n
'WM.J. FOX, COUNTY ENGINEER ADDRESS �C /� ] h
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY eite!,
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FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL �,/
DESCRIPTION LOT N0. OWNER/
BLOCK TRACT 1 -3 a / MAIL .
{ _ADDRESS
NO. OF S
SIZE OF LOT ' " Q NOW ONLOTCITY TEL. N0.
USE OF
BUILDINGS .Q. DISTRICT NO. I GROUP I MAP
CONTRACTOR )) SK PG
Mt �6$QJ:G h � C f.1 �- 00
ADDRESS 4T' „y prt - CONNECTION DATA
CITY ACO TEL. N0. ry�� 6 S^J STATION /' -��iTp . DEPTH e '
REGISTRATION NO. ❑ COUNTY �z��4n /G'V" moi A UPPERNHOLE REFERENCE
� ll7d ,
TYPE OF CONN TION LENGTH FROM f
NO. DESCRIPTION OF WORK FEE Y.N CURB P.L. M.L. TO P L. +�
HOUSE SEWER CONNECTING TO
PUBLIC SEWER t+ $ 3.50
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG. OR CO. IMP. NO. � •� JOB. NO.
_ WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND,ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO. _
SEPTIC TANK, SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL I WASTE APPROVAL
'SPECIAL CONDITIONS ONLY 2.00 CHARGES
PERMIT $ 1 00 CONNECTION CHARGE FEE
'S
OWNER
AUTHORIZATION TOTAL FEE' il r6 REIMBURSEMENT FEE
TRACTORHAVE T TOS CONNECTDATE ONTRTHEA ABOVECTED WDESCR BED EXISITH THE TINGA NAMED DWELLING APPROVALS DATE INSPIECTOR'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF G 19 NEW HOUSE SEWER
OWNER - OR f�. a CONNECT ADDITIONAL
OWNERS AGENT r _ BUILDING OR WORK
SEPTIC TANK, SEEP, PITS)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL[IDRYWELL[IAND 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 1 AM PROPERLY REGISTERED AND/OR D
DISCONNECT PLUG AN
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEW D
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. L BACKFILL SEPTIC TANKS❑
kif J141 (C s fv,a so Py SEEP. PIT(S) ❑ CESSPOOLS
SIGNATURE -
OF PERMITTE '
WILLIAM J. FOX, COTATY ENGINEER VALIDATION
8'3 r us- mAR'2'2 4 4.5'0 m
BY a t. By _ y
DEPUTY DEPUTY 1
•
BY BY
® DEPUTY DEPUTY