HomeMy Public PortalAbout9817 LA ROSA DR_Sewer__ T°A°Ar°
CEBOB 0-60 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS dS•
])OEIN A. LA6IDIE, CounlP Rn poor
CASSATI D. GRIFFIN, sup't of Building LOCALITY
- NEAREST re, ,
FOR APPLICANT"TO FILi. IN __mss
ST.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT //f ` MAIL
ADDRESSNO'OF BLDG
.c.
SIZE OF LOT NOW ON LOTS fid` CITY TEL. NO.
USE OFI
BUILDINGS �,/`/ DISTRICT NO. GROUP BK MAP PROCESSED BY
CONTRACTORPG
ADDRESS T 'CONNECTION/DATA
CITY � TEL.NO. ! STATION � DEPTH
STATE MANHOLE REFERENCE (. �/y / f UPP R
REGISTRATION N0. [. COUNTY
NO. DESCRIPTIO OF WORK EE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ 0,00 TYPE OF CO NECT NGTH FROM _
SEPTIC TANK,SEEPAGE PIT OR Y. B M.L.TO P.L.
PITS AND/OR DRAINFIELD @ S11.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.. CESSPOOL. DRYWELL @ S .00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ Sf 00 CO.IMP. NO. JOB NO.
WORK TOT HOUSE SEWER BLDG.OR @ $i 00 TRUNK PERMIT N0. ROAD PERMIT
- SEWER OR DAISPOSAABANDON
SYSTEM HOUSE @ $100 STATE PERMITENCROACHMENT
PERMIT N0.
INDUSTRIAL
WASTE APPROVAL
CHARGES.
OWNERS PERIvIT $ 2 00 CONNECTION CHARGE FEE -
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA ED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY O 9_ NEW HOUSE SEWER
OWNER OR. `_��- V/ CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPT ICTANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CESSPOOL DRYWELL [I
PLUMBING ❑ SEWER OR _
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM '
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF pBAN00N HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE _
DESCRIBED RESIDENT L ROPERTY. / ,� BACKFILL SEPTI TANKS [ISIGNATURE
SEEP.PITS SS PO LS ❑
OF PERMITTE
u
®r VALIDATION ROBERT A. WOOD
04 tl.Q. CABH SUPERVISING MECHANICAL,ENGINEER
Lr.a L 3 0 2 ^,Pis 3 0 1 0 D 7.0 0