HomeMy Public PortalAbout9621 LA ROSA DR_Sewer__ CE88I°-°2
04 APPLICATION FOR�7ERZMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION SU]LOING
JOHN A. LAMBIE, County Engineer ADDRESS 2 Sa Drive
WILLIAM A. JENSEN, Supt of Building
LOCALITY Temple Cit _
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FOR APPLICANT TO FILL IN CR055 sT.
LEGAL Charles
DESCRIPTION LOT NO. OWNER Charles Dickens
5 NO Or aL MAIL 9621 E. LaRosa Dr .
BLOCK TRACT / () ADDRESS y[li 1 (�
SIZE OF LOT NOWONLOTS CITY Temple Cit TEL. NO. AT 61894
USE .H DISTRICT NO. GROUP MAP PROCESSED BY
BU ILOINGS
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CONTRACTOR I �]t ✓Gy' /
ADDRESS 16203 Indiana Avenue CONNEC 'ION DATA
CITY Paramount TEL. NO. 634-1291 STATI DEPTH
REGISTRATION NO. X1 STATE MAN pLE REFERENCE may/ I
188734 ❑ CDDNTY (
NO. DESCRIPTION OF WORK FEETYPe'd rt�ECTi + LE r H FROM -
HOUSE SEWER CONNECTING TO D � 1. z NB M.L.TO P.L.
PUBLIC SEWER If 55.00 ••
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. /
PITS AND/OR°RAINFIELD SI0.0 CO.IMP. NO. JOB NO. L� [
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT 40.
PRIVATE DISPOSAL SYSTEM ® 53.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER [ni[w[M[ RECORD.INSTR,NO. DATE
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT,GRAINFIELD
EXTN.,C ESSPOOL,DRYWELL.MAN HOLES $5.0
ALTER.REPAIR OR ABANDON HOUSE I HWY.OR ST.WIDENING
SEWER OR DISPOSAL STEM 53- O S1ATE ENCROACHME:tfTA
t r PERMIT NO. •,"-
iR AL
WA5TE APPR0 AL
--1 CHARGES
OWNER c PERMIT s z 00
AUTHORIZATION TOTAL. FEE 0 a CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED COON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL A!
BUILDING OR WORK a/!.f lI l'W�• "
ADDRESS SEPTIC TANK.SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AN0 STATE THAT THE ABOVE 15 CORRECT AND AGflEE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR,SEWER OR
LICEN5 ED AS REQUIRED BV.}OS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 9M {IE LEGAL OWNER OF A INTEND T DISCONNECPLUG AND
RESIDE IN, THE ABO Y SCRIBED RE DENT PERTY. ABANDON HOT USE SEWER +
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMIT, SEEP.PIT ISI ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
cK.
M.0. CASH SUPERVISING MECHANICAL ENGINEER
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