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HomeMy Public PortalAbout9515 LA ROSA DR_Sewer__ D S&E-6R 63 1f-55 i C APPLICATION FOR PERMIT 1 S&E•6 DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL Deportment of County Engineer County of Los Angeles BUILDING JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS i r ® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY NE4REST FOR APPLICANT TO FILL IN ''C'ROSS ST LEGAL OWNER e DESCRIPTION_ LOT N0. MAIL BLOCK TRACT / ♦� AD RESSg� 6i,,,/ NO. OF BLDGS. O SIZE OF LOT NOW ON LOT CITY TEL. N0/f USE OF BUILDINGS // - DISTRICT NO. I GROUP MAP - / BK PG CONTRACTOR 4 � © ® e ADDRESS moi^ .,�, CONNECTION DATA �.J ` STATION DEPTH CITY TEL. NO ,d s 7 (T MANHOLE REFERENCE UPPER ~ [:1 STATE QZO LOWER Y REGISTRATION NO, � �C..,-7 NO. DESCRIPTION OF WORK FEE �— HOUSE SEWER CONNECTING TOY TYPE OF URBJ TION P L LELNGTOH FROM OM � Q PUBLIC SEWER @ $3.50 �=J - SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD Q $3.00 .OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. N0. EXTN.,CESSPOOL,DRYWELL,MANHOLE Q $2.00 CO. IMP. NO. JOB NO. HOUSE SEWER CONNECTING TO q� //f PRIVATE DISPOSAL SYSTEM Q $1.00 ` TRUNK PERMIT NO. ROAD PERMIT N0. 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 I TOTAL FEE REIMBURSEMENT FEE 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE_ INSPEC TOR'SSIGNATURE TRACTOR TO CONNECT THE ABOVE DE RIBED EXISTING DWELLING - TO THE PUBLIC SE ERR.. NEW HOUSE SEWER -- SIGNED THIS--� e N 'DAY OF 19 CONNECT ADDITIONAL OWNER OR BUILDING OR WORK OWNERS AGENT SEPTIC TANK,SEEP,PIT(S) ADDRESS AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLIC ION 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 I AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RESIDEN PROP BACKFILL SEPTIC TANKS❑ _- SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS OF PERMITTE JOHN A. LAMBIE, COUNTVLNGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR CK. M.O. CASH