HomeMy Public PortalAbout9812 LA ROSA DR_Sewer__ TEMPLE
7CA641°-BzD APPLICATION FOR PERMIT
CE808
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
` BUELDING AND SAFETY DIVISION BUILDIrvG �, pp
JOHN A. LAMBIE, County Engineer AEDREss
WILLIAM A. IENSEN, Sup't o1 Building LocBElry fi
NEAREST
FOR APPLICANT TO FILL IN , CR05S ST. �'
LEGAL /� Tr
DESCRIPTION LOT NO. '� fqv - OW NERry A. /}�R/t G
A MAIL / IY�-P'7-
BLOCK TRACT I� ADDRESS _ A`
// J ANO. OF SLOGS.
512E OF LOT CJ/V `v NOW ON LOT CITY TEL. NO,
USE OF DISTRICT NO. GROUP MAP PROCE55EI BY
CONTRACTOR
BUILDINGS '� G BK PG
CONTRACTOR
ADDRESS !3r � - j' ]" f CONNECTION DATA
CITY j.._ TEL NOA CI G STATION f
I E b DEPTH
❑ STATE UPPER
REGISTRATION NO. �� G ❑ COUNTY MANHOLE REFERENCE LOWER T
a
N0. DESCRIPTION OF GRK FEE TYPE OF CONNECTION LENGTH FROM O
HOUSE SEWER CO NNECTING TO Y, CURB P.L. M.L.TO P.L. V
PUBLIC SEWER @ 55.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO,
PITS AND/OR DRAINFIELD @ 510.00 CO,IMP. NO. JOB NO. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO, V
PRIVATE DISPOSAL SYSTEM @ $3.00 W
CONNECT ADDITIONAL BLDG.OR gFFIDAVIT my IO,.NT RECORD. INSTR_NO. DATE a
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.GRAINFIELD
E%TN..CESSPOOL.BRYWELL.MANHOLE@ $5.00 /1�^ ._ D
ALTER,RIQIAJ4 Y}lWfpCNTtiYGE A� ..N
HWY. °R 1V
SEWER ' SYSTEM @ 53.00STATE ENCROACHMENT
PERMIT NO.
17) 113
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s
AUTHORIZATION TOTAL FEECONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE REIREIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCP IBED E%15TING °WELLING
TO THE PUBLIC SEWER, APPROVALS - DATE INSPECTORS SIGNATURE
SIGNED THIS DAY OF-19—
OWNER
F19_OWNER OR A NEW HOUSE SEWER
OWNERS AGENT����
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,BEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AN DRAINFIELD
AMC STATE THAT THE ABOVE IS CORRECT AND AGREE To COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWER$, CESSPOOL ❑ ORYWCLL ❑
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REDUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTE M
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESI/D�EN71AL PROPERTY, ABANDON HOUSE SEWER
SIGNATURE /
BACKFIL
'fY/A�i.���(.-
OF PERMITTEE BACKFILL SEPTIC TANKS
❑
SEEP,PITS) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
CK. M.O. CASH. SUPERVISING MECHANICAL ENGINEER
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