HomeMy Public PortalAbout9425 LAS TUNAS DR_Sewer__ 6424 -CEBDE -'°_" APPLICA ION FOR ERM IT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FADDRESS
L S T�/ �'S
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FOR APPLICANT TO FILL IN p.
LEGAL ,I
DESCRIPTION LOT NO. OWNER �� (J L� t
MAIL
BLOCK TRACT �� (p 1 ADDRESS G LV �Ji f
'N'OW
OF BLDGS. ^ -
SIZE OF LOT `� Q �O NOW ON LOT �' CITY C"�+ TEL. NO.
USE OF - -
BUILDINGS % DISTRICT NO. GROUP MAPO_L9�c
D BY
BK 1 P3
CONTRACTOR U' G ` gv ,0 S > / jADDRESS C E—iUTUA( flL v/► , CONNECTION DATA
CITY �+ TEL. NO. 757C G J_ STATION "2,
DEPTH
UPPER
STATE T LIC // MANHOLE REFERENCE R
LICENSE NO. Q 3 T GLASS _ 1.
NO. .DESCRIPTION OF WORK FEE TYPE OF CONNECTIONLENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P:L. M.L.TO P.L.
PUBLIC SEWER @ $7..00P.C.NO.
SEPTIC TANK,SEEPAGE PIT.OR
PITS AND/OR DRAINFIELD _ @ 510.00 CO. IMP. NO. JOB NO.
HOUSE.SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. a
PRIVATE DISPOSAL SYSTEM' @ S3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I"EASEMENT RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER @ 53.00
OVERFLOW SEEPAGE PIT.DRAINFIELD I Qom/
EXTN..CESSPOOL.DRYWELL. @ S5.00 WIDENING OR ST.
ALTER.REPAIR OR ABANDON HOUSE HWY. 0
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT _ W
MANHOLE PERMIT NO. a
$7.00 INDUSTRIAL I N
WASTE APPROVAL Z
OWNERS PERMIT s s 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE Cl cro,
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 INSPECTORS SIGN URE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER X167/
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 '
WITH ALL COUNTY ORDINANCES .AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,.RE PAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PER MrrTEE SEEP,PIT(S) ❑ CESSPOOLS ❑
VAI TION CK'
M.O. CASH
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