HomeMy Public PortalAbout9916 LA ROSA DR_Sewer__ &) -66 3 9.55
EAPPLICATION FOR PERMIT
B O E.66
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment o! County Engineer
County of Los Aagolea auaDING
WM.J. FOX. COUNTY ENGINEER ADDRESS 7—e-
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K CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY / Fem pQ/� el F 1
FOR APPLICANT TO FILL IN NEAREST f�� N S
CROSS$T.
LEGAL Z
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAIL
ADDRESS pas
am r ��( n Dj-'
NO. OF BLOGS. �• I, Q/
SIZE OF LOT NOVI ON LOT CITY J~ �J TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP
BK PG
CONTRACTOR &mz n ,A / T G q.3
ADDRESS `/- <i•/ CONNECTION DATA T
CITY TEL. NO. STA kiON DEPTH
1 [I STATE MANLE REFERENCE UPPER
REGISTRATION NO. ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE 0 CONNECTION LENGTH M
PUBLIC SEWER Q $ 3.50 Y. C B P.L. M.I. TOTYPE .L.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR P. . NO.
--WORK TO HOUSE SEWER 1.00 CO. IMP. NO. 411 NO.
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM I.00 TRUNK PERMIT NO. ROAD PERMIT NO.
/ DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
I AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD .00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTIreN CHARGE FEE
WPERMIT 1 DO
OWNER'S PERMIT
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER --
SIGNED THIS__DAY OF 19 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK _
SEPTIC TANK. SEEP, PIT(S)
ADDRESS AHD/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
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
LICENSED AS REQUIRED Y LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND ^
CALIFORNIA OR THAT A THE LEGAL WNE THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENT] ERTY. BACKFILL SEPTIC TANKS❑ ttc-
SEEP. PIT(5) ❑ CESSPOOLS�ff' 1 C•IA• /' ___
SIGNATURE
OF PERM ITT
WILLIAM J.FOX. COUNTY ENGINEER VALIDATION R.A. WOOD, CHIEF PLBG. INSPECTOR
j�7 8 1 0" JUL
5 4 (1 0 L•
6
5&E.663 3.39 APPLICATION FOR PERMIT _ 7
3 S 66 1
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer /r
County of Loo Angeles BUILDING
WM.J. FOX. COUNTY ENGINEER ADDRESS 47
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY - e
M=M
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL
DESCRIPTION LOT N OWNER S y��j,
BLOCK TRACT MAIL �f
ADDRESS
`''� •''� OF
1 V )f�� NOW ON U� CITY—=7 TEL. N0.
SIZE OF LOT
USE OF
BUILDINGS D
ISTRICTGROUP MAP
8K PG
CONTRACTOR
ADDRESS Q G i S'TONNECTION DATA
CITY �p�EL. NO. ��� 6�[MANHOLE
S DEPTH
� ❑ STATE �/ Q l EA.5r L0�
REGISTRATION N0. /O �T"
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO '}� TYPECU9B P NECTIONL M1f L TLENGTOPLH FROM
PUBLIC SEWER Q $ 3.50 p Y
---ttt--- HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00CONN _ �qi
WORKECT ADDITIONAL TO HOUSE SEWER 1.00
OR P C N
O.
1.00 O CO. IMP. NOJ/O�
OB N0..
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT 10.101
Qa4
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.O0 PERMIT NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS PND/OR GRAINFIELD .00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
PERMIT CONNECTION CHARGE FEE
OWNERS $ 1 00
AUTHORIZATION TOTAL FEE $jj REIMBURSEMENT FEE
IHAVE MED CON-
TRACTORTTOS CONNECT THE DATE ABOVEWDESCRIBED EXISTING WITH THE HEREIN A DWELLING APPROVALS DATE INSPE TOR'S SIGNATURE
TO THE PUBLIC SEWER 1
SIGNED THIS F F 191 NEW HOUSE SEWER 2 /J __/
OVfNER OR CONNECT ADDITIONAL V
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK. SEEP. PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY fCACTWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYW'ELL❑
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
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
LICENSED AS REQUIRED BY LOS ANGELESCO,JV,' Y AND ATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL '7V (ER 0 ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY- BACKFILL SEPTIC TANKS❑
SEEP. PIT(S) ❑ CESSPOOLS CI
SIGNATURE
OF PERMITT
WILLIAM J. Fff COUNTY ENGINEER VALIDATION R. A. WOOD, CHIEF FLOG. INSPECTOR
i� a7585 ', &129 4 6.5 ' ' ID