HomeMy Public PortalAbout9533 LA ROSA DR_Sewer__ V
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76A642D APPLICATION FOR PERM
6A642lJ
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICA!y TO FILL IN CROSS 5T
LEGAL '
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT Z �./ ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL. NO ------- -
USE OF DISTRICT NO. GROUP MAP PROCESS BY
BUILDINGS t.[// BK PG r
CONTRACTOR 1�1
ADDRESS CONNECTION (DATA
CITY CjEL NO G F& 00r/ STATION E T
ATE MANHOLE REFERENCE UPPER
REGISTRATION NO (� 3 COUNTY LOWER
NO. DESCRIPTION OF WOR FEE TYPE OF CONNE T ON L GTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L ML TO P L. g
PUBLIC SEWER @ $5 00 v
PC NO
SEPTIC TANK,SEEPAGE PIT OR V
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER I EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN,CESSPOOL•DRYWELL,MANHOLE @ $5.00 ° .N�jj,,••
ALTER. ORST HWY. OST WIDENING L
SEWER QR..D4.5R06A.6 SYSTEM @ $3.00 W STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s 2 00
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION I TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF t9_
OWNER OR NEW HOUSE SEWER 1
OWNERS AGENT_ CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK.SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL Cl DRYWELL ❑
I HEREBY CERTIFY THATY�S
M PROPERLY REGISTERED AND/OR ALTER..REPXfR.SEWER OR 1{ �,-_� j�>r,`
LICENSED A IRED BANGLES COUN Y AND STATE OF SEWAGETDISP_OS'P:L4NSTEM.CALIFORN�OR T T 1 LEGALOWNAND INTEND ORESIDE I ED RESID L PROPERTY DISCONNECT PLUG AND O
ABANDON HOUSE SEWER
SIGNATURE ` BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
SEEP,PIT(S) El CESSPOOLS
OVALIDATION ROBERT A. WOOD
M.O. CASH SUPERVISING MECHANICAL ENGINEER'
CK_
LACO 7 4 1 31 NOV 2 6 1 0 D 5.00- Q