HomeMy Public PortalAbout9851 LA ROSA DR_Sewer__ 4465O.INSERTS
DEa°BeBOAPPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL'.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRESSG A O,S' A
JOAN A. LAMBIE, County Engineer -.
WILLIAM A. JENSEN, SuP'I of Building .LOCALITYNEAREST
C�
FOR A C T TO FILL IN
CROSS ST. 'J
LEGAL - -
DESCRIPTION LOT 0. OWNER '
BLOCK TRACT MAIL
ADDRESS
N0.OF BLOCS. ,
SIZE OF LOT NOW ON LOT CITY TEL..N0.
USE
CONTRDICTBK DISTRICT NO. GggOUP MAP I J!RQCESSED BY
PG
CONTRACTOR
ADDRESS CONNECTIOD DATA
CITY TEL.NO./ STATION 3 DEPTH
'STATE MANHOLE REFERENCE
REGISTRATION NO. ® COUNTY440 1 ; LOWER
NO. DESCRIPTION OF WORK FTE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
PITS AND/OR DRAEPTIC TANK. ENFGELDNT OR @ $3.00 I - CUR..---f M.L.TO P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL. DRYWELL @ $2,00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 'CO. IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. p
WORK TD HOUSE SEWER SI.00 V
ALTER,REPAIR OR ABAND N USE STATE ENCROACHMENT m
SEWER DR DI SPOSA :SYS / @ $L00 PERMIT NO. p
INDUSTRIAL - U
WASTE APPROVAL W
CHARGES N
OWNER'S PERMIT $ - CONNECTION CHARGE FEE b
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS —DD/AY OP 19 'NEW HOUSE SEWEROWNER DR
OWNERS AGENT__ / CONNECTA
BUILDING ORRWORNAL WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE_THAT I .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 ALTER„REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT k VTHE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIA P PERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE
SEE .PIT(S) El CESSPOOLS ❑.
OF PERMITTE
®' VALIDATION--1 ROBERT A. WOOD
CR. M.0. (`CASH/J SUPERVISING MECHANICAL ENGINEER,
L&023 7G JUL20 1 1 D 25,00
a*ERTS ,
�DE6066.60 , APPLICATION FOR PERMIT
.]6A642Y • •COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION _ .ADDRESS ds
ADDRESS
I01IN A. LAMBIE, County Evginver
'WILLIAM A. JENSEN, Sup't of Building LOCALITY
FOR AP CANT TO FILL IN caoss sr.
LEGAL
DESCRIPTION LOT t ! OWNER
BLOCK TRACT !a �/ MAIL /
�tA' ' 'ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON-LOT 'CITY TEL. NO.
USE OF
BUILDINGS �� DISTRICT NO. GROUP MAP PROCESSED BY -
/ B PG
CONTRACTOR
ADDRESS S' )- CONNECTION DATA I -
CITY ,,� TEL.NO. (7 1 � (jl>y STATION DEPTH
Q ^J / ❑ STATE MANHOLE REFERENCE
REGISTRATION N0. /J %�� ❑. COUNTY -LOWER
NO. DESCRIPTION OF W RK FEE
HOULIC SEW R CONNECTING TO @ $3.00 1
TYPE OF COt ON LENGTH FROM -
SEPTIC TANK,SEEPAGE PIT OR Y. P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT. DRAINFIELD
EXTN..CESSPOOL. DRYWE LL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ 51.00 CO. IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG. OR TRUNK PERMIT NO. ROAD PERMIT NO. p
WORK TO HOUSE SEWER @ 51.00 U
SEWER OR DISPOSAL SYSTEM HOUSE @ $t 00 STATE ENCROACHMENT m
PERMIT NO. O
INDUSTRIAL
WASTE APPROVAL -
CHA GES N
OWNERS PERMIT $ 2 �0f.00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE r/f/ REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- _
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. .� LI
SIGNED THIS DAY OF -- 19_ NEW HOUSE SEWER -
OWNER OR CONNECT ADDITI ON AL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP. PIT(S)
AND/DR DRAINFIELD
I 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 ALTER,REPAI R,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON CT PLUGHOUSE AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RES IDENTI P PERTY. i- BACKFILL SEPTIC TANKS LlSIGNATURE
l SEEP.PIT(S) ElCESSP OLS ❑
OF PERMITTEib
®r VALIDATION ROBERT A. WOOD -
cIL B.0. usB SUPERVISING MECHANICAL ENGINEER
�0 2 30 2 3 6 JUL �Q 1 D 5 .0 0 M