HomeMy Public PortalAbout9518 LA ROSA DR_Sewer__ - D
S&E6e . APPLICATION FOR- PERMIT 1 '
8$E DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE D I SPOSA L
Deportment of County Engineer
- County of Los Angeles- BUILDING
-JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN. SUPT OF BUILDING LOCALITY C.C �
FOR APPLICANT-TO FILL IN CROSS ST.
LEGAL OWNER -
DESCRIPTION LOT NO. _
MAIL
BLOCK TRACT ADDRESS
O. OF BLDGS / CITY TEL. NO.
SIZE OF LOT NOW ON LOT
USE OFDISTRICT NO. GROUP MAP
_ BUILDINGS
BK PG
CONTRALTO v� L / D d .
ADDRESS CONNECTION DATA
/jam ® _ � STATION C;)— ,DEPTH
CITY .� N0./'T( /7y MAN HOLE'REFERENCE
❑ STATE L E
REGISTRATION NO. ❑ COUNTY
No. DESCRIPTION 0 WORK FEE
HOUSE SEWER CONNECTING TO YPE OF CONNECTION LENGTH FROM
CURB P.L. M.L. TO P,L.
PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD / P. C. NO.
EXTN'.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. NO. (J JOB NO.
HOUSE SEWER CONNECTING TO 4,^ ,/
PRIVATE DISPOSAL SYSTEM Q $1.00 TRUNK PERMIT NO. • ROAD PERMIT N0.
CONNECT ADDITIONAL BLDG,OR STATE ENCROACHMENT - -
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVAL '
CHARGES
CONNECTION CHARGE FEE -
OWNER'S PERMIT s 1 o0
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE -
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON- APPROVALS_ _ DATE _ INSP CTOR•SSIGNA SURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER - v� AA-
SIGNED THIS DAY OIF 19 CONNECT ADDITIONAL
OWNER OR ^ / BUILDING OR WORK
OWNERS AGENT 4 SEPTIC TANK,SEEP,PIT(S)
ADDRESS' - AND/OR DRAINFIELD
I 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
CALIF RNIA OR THAT I THE LEGAL OWNER OF THE ABOVE
DES BED ESIDENTIAL OPERTY. BACKFILL SEPTIC TANKS❑
SIG'41 ❑ CESSPOOLS❑
OF E 1
JOHN A. L BIE, COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. m 0. CASH
LG 3 0,_1 4 APR 17 4 A 450 M