HomeMy Public PortalAbout9406 LAS TUNAS DR_Sewer__ 6A642D 0-63
76A642APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS �p 7 /
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER Q/
MAIL
BLOCK TRACT ADDRESS
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT CITY L. NO.
USE OF
DISTRICT NO. GROUP MAP PROC SED BY
BUILDING .O BK PG `
CONTRACTOR
a.+v ti e. L —
ADDRESS �.� CONNECTI N DATA
CITY TEL. NO. �® STATION h DEPTH /
❑ STATE MANHOLE LOWER
REFERENCE/V —
REGISTRATION NO. ❑ COUNTY
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 @ 55.00 0U P.C.NO. d
SEPTIC TANK,SEEPAGE PIT OR JOB NO. O
PITS AND/OR DRAINFIELD @ SI0.00 CO. IMP. NO.
U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 9x
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVrR EASEMENT RECORD. INSTR.NO. DATE O
WORK TO HOUSE SEWER @ $3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD L7J
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00 d
ALTER,REPAIR OR ABANDON HOUSEHWY.OR ST.WIDENING h
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
OWNERS
INDUSTRIAL
WASTE APPROVAL
CHARGES
$ 00
CONNECTION CHARGE FEE
AUTHORIZATION PERMIT TOTAL 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 D;A'�E ITOR' SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WIT HALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 1 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 ABO ESCRIBED RESID NTIAL PROPERTY.. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC NKS ❑
OF PERM ITTEE� SEEP,PIT(S)
CESSPOOLS ❑ �J
VALIDATION ROBE r NOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. ASH