HomeMy Public PortalAbout9561 LA ROSA DR_Sewer__ CE808 3 62 0 1 APPLICATION FOR PERMIT
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COLTNiY O'F LOS ANGELES SEWER-SEWAGE DISP SAL
DEPARTMENT OF COUNTY ENGINEER -
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BUILDING AND SAFETY DIVISION SU ILDI NIG 10!9:1-11.011
COU Y SS
5 1 r
JOHN A LAMBIE, COUNTY ENGINEER ADDRE S
COLEMAN W JENKINS SUP T OF BUILDING
A IT,
LOCALITY -Te M D Ile, Cy I
NEAREST t
4T To L I C 0
C 0
FOR APPLICANT TO FILL IN R SS ST 6 mpie,
IPTION LOT NO
SLEGAL )
DE CR OWNFR ?01
MAIL
BLOCK TRACT 1.3 Z, Z 0 ADDRESS eO,74q
NO OF BLDG5
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO jrR,0UPI MAP E6sSEp BY
P. P I
CONTRACTOR
ADDRESS CONNECTION DAT
STATION DEPTH
CITY TEL NO
STATE LIC MANHOLE REFERENCE UPPER
LICENSE NO GLASS LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
I H >
OUSE SEWER CONNECTING TO Y CURB P L M L TO P L 0.
P UBLIC SEWER @ $5 00 PC NO 0
SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO
PITS AND/OR DRAINFIELD sl000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ S3 00 1 0
CONNECT ADDITIONAL 06opmow AFFIDAVIT �AIVER I EASEMI.T RECORD INSTR NO DATE
K S oo I
WOR TO HOUSE EWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD CL
EXTN CESSPOOL DRYWELL MANHOLE @ S500 U)
ALT E R REPAIR OR ABANDON HOUSE HWY OR ST WIDENING z
SEWER OR D ISP OSAL SYSTEM @ $3 O� STATE ENCROACHMENT I
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OVvrNER'S PERMU s 2 00 C.ARGES
AUTHOMOZATION�TOTAL FEE z CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT F�E
T RACTO R T 0 CONNECT HE ABOVE DESCR6BED EXISTifNG DWELLING
TO THE PUBLIC SEW APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
9,�6_ T
CONNEC ADDITIONAL
r BUILD]N G OR WORK
ADDRESS
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
WITH ALL COUNT Y ORDINANCES AND STATE LAWS REGULATING
PLU ME,ING AND SEWERS CESSPOOL El DRYWELL [:1
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER RE PAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGL ES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORN I A OR THAT I AM THE LEG L OWNER OF AND INTEND TO DISCONNECT PLUG AND
RES 10 E IN THFqBOVE DESCRI AL P OPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS
EE SEEP PIT(S) [I CESSPOOLS
VALIDATION JACK R. ALLEN
CK M 0 ��CASS UPERVISING MECHANICAL ENGINEER
LACO 7 1 3 4,% NOV 6 1 0 D 5.Q 0