HomeMy Public PortalAbout9962 LA ROSA DR_Sewer__ CEB09 10-63 APPLICATION FOR P MIT
76A6420
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE. County Engineer ADDRESS
WILLIAM A. TENSEN. Supt of Building J •L
LOCALiTV �l
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO ��/�
MA I
B/LL CK L TRACT • j ADDRESs_j01;
5 T • R TY �- : T.L. NO.
5E DISTRICT NO. GROUP MAP PR OCESSE.BY
CONTRACTOR 9 �( �I�• �'V
ADDRESS — _ y CONNECTION DATA
CITY 77 TEL 2• STATION ;'� DEPTH
STATE
REGISTRATION NO,
rL 02f.2� ❑ COUNTY MANHOLE flEFEflENCE
NO. GESCRI PTION OF WORK FEE ��LL{ ((��__�� TYPE OF CONNECTION LENGTH FROM /�
POBLIC SEW ERGO NNECTING TO 35.00 V (TV Y. CURB P.L. M.L.TOP,L, �J /
d
SEPTIC TANK.SEEPAGE PIT OR J�J' P.0.N0. O
PITS ANO/OR DRAINFIELD $1000 CO.IMP. NO. / 3OS JOB NO, v
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO, ROAD PERMIT N0./ /D (Y
PRIVATE DISPOSAL SYSTEM $3.00 J/Q 1 ^
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT Alv[R RSL RINI RECORD. INSTR.NO. DATE VF..
WORK TO HOUSE SEWER ® S3Oo v
OVERFLOW SEEPAGE PIT.DRAINFIELD W
EXTN_CE55POOL,ORYWELL,MA N HOLE C ISO. - d
ALTER.REPAIR OR ABANDON HOUSE HWY,OR ST.WIDENING N
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT Z
PERMIT NO.
INDUSTRIAL
W ASTE APPROVAL
OWNER'S PERMIT s z 00 CHARGES
AUTHORIZATION TOTAL FEE 7 !.l CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED�CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER, APPROVALS DATE INSPECTOR'S$IG NAT;R c�
SIGNED THIS DAY OF 19_ �y , r 6
OW HER OR NEW HOUSE SEWER NIT1j[pR1.
OWNERS AGENT CONNECTADDITIONAL
BU ILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP.PIT15)
HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE ICORRECT AND AGREE COMPLY
WITH ALL COUNTY ORDINANCES
S AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYW ELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR.SEWER OR
LICENSED AS REOUIREO BY LOS ANGLES TY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 HE LEGAL ER DWI
TEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB BCRIBEO RE NTIAL PR R Y. gBANDON HOUSE SEW ER
SIGNATURE BACKFILC.SEPTIC TANKS ❑
OF PERMITTEE SEES,PITS) ❑ CESSPOOLS ❑
VALIDATIO ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK, M.O. CASH
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