HomeMy Public PortalAbout9926 LA ROSA DR_Sewer__ 90A642D
98E8MAPPLICATION FOR PERMIT
1
DIVISION OF RUMDING AND SAFETY SEWER—SEWAGE DISPOSAL
Depoxtment of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLI NT TO FILL IN caoss sT.
LEGAL / OWNER
DESCRIPTION LOT NO
MAIL
BLOCK TRACT ADDRESS
N0. OF BLDGS. CITY TEL. NO.
SIZE OF LOT h _ NOW ON LOT
USE OF DISTRICT NO. GROUP MAP
BUILDING$ PK PG
CONTRACTOR
CONTRACTOR i�•L!u� l�//�/�j��
ADDRESS p J CONNECTION DATA
/ �Sl �• �j'
CITY� �j- ,E TEL. NO.�z :1—/��_s STATION��J DEPTH
{{ •-t, MANHOLE REFERENCE PPER
REGISTRATION NO.IL// �+ z7"� - 7 [I COUNTY
` V
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TOS. TYPE OF CONNECTION LENGTH FROM
q� Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $3.w ®GY
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. N0.
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. NO. Q 16B NO. �j ''')
HOUSE SEWER CONNECTING TO / v /
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO. / _
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER a S 1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $I.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 00
�� REIMBURSEMENT FEE
AUTHORIZATION TorAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER,
SIGNED THIS DAY OFI& BUILDING
ADDITIONAL
OWNER OR ,wV BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 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 ALTER,REPAIR.SEWER OR
PLUMBING AND SEWERS. 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
HO PLUGA D
CALIFORNIA OR TH,p T.� AMCAT E LEGAL OWNS/ ABOVE
DES CRIBEO RE3EI' ER
D`JE`yN7JiJ{L PROP
TY. / (`�V!?l'//�. 1 < BACKFILL SEPTIC TANKS❑
SIGNATURE /�� �� SEEP. PIT(S,
ITIS7 ❑ CESSPOOLS❑
OF PERMITTE 9�
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A.WOOD. CHIEF PLBG. INSPECTOR
CN. M.0. CASH
LACo 6 2 .2 3 �— GCT 3 O 1.0 A 5 .00