HomeMy Public PortalAbout9040 LAS TUNAS DR_Sewer__ . �.
AI543-64,
762D� �. APPLICATION FOR PERMIT
A64
COUNTY,OF LOS ANGELES SEWER—SEWAGE DIS SAL
DEPARTMENT OF COUNTY ENGINEER
' BUILDING AND SAFETY DIVISION BUILD
INGED O
JOHN A. LAMBIE, County Engineer ADDRSS
WILLIAM A. JENSEN, Supt of Building ,
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
!� MAIL
BLOCK TRACT \l ADDRESS
NO OF LDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS /]J SK •'PIS �
CONTRACTOR //AAa
ADDRESS �Z CONNECTION DATA
CITY q .2j,)3
TEL NO o2� : ,g /s9 3- STATION � EPTH
� D
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REGISTRATION NO 2'm / T(u/3 COUNTY MANHOLE REFERENCE /0 / LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH F M D
HOUSE SEWER CONNECTING TO pY CURB P L M L TO P
PUBLIC SEWER ® 5 .00 _ PC NO
SEPTIC TANK,SEEPAGE PIT OR
PITS AN D/OR DRAINFIELD 5;0 00 CO, IMP NO JOB NO D.
O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO. U
PRIVATE DISPOSAL SYSTEM $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVII I [AirNrNT RECORD INSTR NO. DATE
WORK TO HOUSE SEWER ® $300 O
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN,CESSPOOL,DRYWELL.MANHOLE Q 3500 V
W
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING D_
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT N
PERMIT NO, Z
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S 00 CHARGES
AUTHORIZATION TOTAL FEE zo Or
CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TOATHERTO CONNECT PUBLIIC SEWER THE ABOVE DESCRIBED EXISTING DWELLINGAPPROVALS
DAT INSPECT O '8 SIGNATURE
SIGNED THIS DAY OF 19_ / /
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP,PITS)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESC IBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP.PIT(S) ❑ CESSPOOLS ❑
LMATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
8 7 5-*-' JAN 7 1 0 D 1 0.00-