HomeMy Public PortalAbout9811 LA ROSA DR_Sewer__ TFA°`2°
cceoe 8.39 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
])OHN A. LAMBIE, County En nae:
CASSATT D. GRIFFIN, Supt of Euildinq LOCALITY
NEAREST
jr APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT l MAIL
ADDRESS
NO.OF BLDGS. e
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF y�
BUILDINGS DISTRICT N0. G ROU2J MAPPG CESSED BY
CONTRACTOR /f l L{� I ADDRESS PG Lam' COFFF--NNECTION/DATA
CITY 'JI TEL NO. STATION .DEPTH
f'T STATE MANHOLE REFERENCE f,' �J UPPER
REGISTRATION N0. ORK Q B COUNTY XiJ' �D1yE{ty
NO. DESCRIPTION OF WFEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $I-00 I
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PITS AND/OR DRAINFIELD @ S .00 Y. CURB
OVERFLOW SEEPAGE PIT. DRAINFIELD
EXTN..CESSPOOL.DRYWEL L @ $ .00
HPRIVATE DISPOSAL SYSTEM OUSE SEWER CONNECTING TO P.C.N0.
@ S .00 CO.IMP. N0. JOB N0.
WORK TCT O HOUSEISEWERB BLDG.OR @ 00 TRUNK PERMIT N0. ROAD PERMIT N0.
ALW EROP UAI SP SAL SY STEM HOUSE @ 00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT g Z 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAED CON"
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 79_ NEW HOUSE SEWEROWNER OR
OWNERS AGENT CONNECT ADDITIONAL /
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP. PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER.REPAIR,SEWER OR
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 DISCONNECT
HOUSE SEWER
CALIFORNIA OR THAT 1 M THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTI L OPERTY. BACKFI LL SEPTIC TANKS LlSIGNATURE i
SEEP.PIT(S ❑ CESSPOOLS [71OF PER MITTE
®F VjI],jDA'I'ION-----� ROBERT A. WOOD _
to Y.o. usx SUPERVISING MECHANICAL ENGINEER
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