HomeMy Public PortalAbout9903 LAS TUNAS DR_Sewer__ 76A 642D -C E808 -10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION F-AEST
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FOR APPLICANT TO FILL IN
LEGAL JJ
DESCRIPTION LOT NO. t' OWNER
,fir♦ MAIL
BLOCK TRACT ,' j ADDRESSf �t�� I f+•
f NO. OF BLDGS.
SIZE OF LOT '"`f NOW ON LOT ..5,,. CITY I TEL. NO. -
USE OF
BUILDINGS* . ��.,., DISTRICT NO. GROUP 8K MAP Po PROCESSED BY
CONTRACTOR
ADDRESS CONNECTION DATA
,,. ,• STATION ,+ rb DEPTH "
CITY •- TEL. NO. F
STATE LIC1I. UPPER
LICENSE NO. CLASS MANHOLE REFERENCE r" OWER"
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB •p.L.? M.L.TO P.L.
PUBLIC SEWER 0 $7.00 P.C.NO.
SEPTIC SANK.SEEPAGE PIT OR f JOB NO. d
PITS AND/OR DRAINFIELD $10.00 CO.IMP.NO. - O
I' HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM @ $3.00 LLJ
CONNECT ADDITIONAL BLDG.OR - AFFIDAVIT wuvER EIISFMFNt RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL. 0 $5.00 >-
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING GC
SEWER OR DISPOSAL SYSTEM 0 $3.00 STATE ENCROACHMENT �
MANHOLE 0 $7.00 PERMIT NO. O
INDUSTRIAL LL
WASTE APPROVAL
CHARGES L1.1
OWNER'S PERMIT s 3 00 t'
AUTHORIZATION TOTAL FEE 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 SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP.PIT(S)
1 HEREBY ACKNOWLEDGE THAT I 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 CESSPOOL ❑ DRYW ELL ❑
PLUMBING AND SEWERS.
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 DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE /
OF PER MTTTEE r f BACKFILL SEPTIC TANKST
SEEP.PIS) ClClCESSPOOLS ❑
VALIDATION K. M.O. CASH
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