HomeMy Public PortalAbout9030-9030 1/2-9032-9032 1/2 RANCHO REAL RD_Sewer_1975-08-15 Z-1)
'6A 6420 CE808 - 9/73
1. APPLICATION R PERI it' Li
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING;_f-` -dtfl, 2
ADDRESS
LD I NG41
ADDRESS
LOCALITY
BU'7A
FA
LD-
LOCALITY
NEAREST
EAREST
FOR APPLICANT TO FILL IN CROSS
,,LEGAL ✓W
_D_ CR IPTION LOT 0. OWNER
.AIL
BLOCK TRACT4ADDRESi,�S/
NJOF SLDGS.
SIZE OF LOT ON LOT CITY TEL. NO.
USE OF
DISTRICT NO. GROUP I MAP CESSED BY
BUILDINGS SK p s
GONTRACTOR.,
({zc
ADDRESS STATIJ CONNECTMN nATl-
CITY DEPTH
STATEL C MANHOLE REFERENCE > UPPER
LICENSE NO, CLASS 4001110111911--
NO. [ DESCRIPTION OF WORK FEE — TYPE OF=N19N LENGTH FROM
Y. 44--
HOUSE SEWER CONNECTING TO CURB M.L.TO P.L.
PUBLIC SEWER @ $7.00
SEPTIC TANK.SEEPAGE PIT OR A.C.NO.
PITS AND/OR.DRAiNFIELD $10.00 CO.IMP. NO. J013 NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00
!JZ
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT RECORD.INSTR.NO. DATE
WORKTO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT,DRAfNFIELD
-
Q
-EXT NCESSPOOL.ORYWELL. a $5.00 HWY.OR ST.WIDENING
ALTER.REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $3.40 STATE ENCROACHMENT C�l
MANHOLE0 $7.00 __PERMIT NO. r,
INDUSTRIAL W0-
WASTE APPROV)
CHARGES
1
OWNEWS P
---I ERM300
IT $11 ( 11,11CTI.N CHARGE FEE
AUTHORIZATION I TOTAL FEE j
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- APPROVAf§ D.j!_j INSPECTOR'S SIGNATURE
SIGNED THIS—DAY OF —19—
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS----__
SEPTIC TANK.SEEP P'T(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AN D STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
RS. CESSPOOL El DRYWELL [I
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LI
C E NSE DAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CAL ,R
IFCN IA OR THAT I AM THE LEGAL OWNER OF, ND INTEND TO DISCONNECT UG AND
OF
RESIDE IN. THE ABOVE DESCRIBED RESIDENTIAL OPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL,SEPTI TANKS ❑
OF PFQMI`TTEE-'��f C CESSPOOLS
SEEP.PIT(S) 0
VALIDATION CK. M.0. CASH
Or-'AUG 15 :1, V0