HomeMy Public PortalAbout9034 RANCHO REAL RD_Sewer_1975-08-15 '6A FA2D CE808 - 91/73 APPLICATIC* FOR POMIT
COUNTY OF LOS ANGELES !EWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER BUILDING BUILDING AND SAFETY DIVISION - 3F
ADDRESS DRESS
C�
LOCALITY
FOR APPLICANT TO FILL IN _ROSSNEAREST ST.
LEGAL
_DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADORE"
NO.
F BLDGS:
SIZE OF LOT � o
.w .. N LOT CITY TEL. NO.
USE & -
BUILDINGS DISTRICT NO. GROUP I MAP CE$SED BY
8K PS
CONTRACTOR..,
ADDRESS CONNECTION DATA
STATION DEPTH
CITy
TEL. NO.
STA E LIC MANHOLE REFERENCE UPPER
LICENSE N O;� CLASS
NO, DESCRIPTION OF WORK FEE TYPE OF CONNECTIO LENGTH FRO any
"OUSE SEWER CONNECTING TO Y
PUBLIC SEWER
P.C.NO.
SEPTICTANK,--SEEPAGE-PIT OR CO.IMP.NO. JOB NO.
PITS AND/OR DRAINFIELD $lo.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
_PRIVATE DISPOSAL SYSTEM $3.00 2�/
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wA1YEC EASE FIE NT RECORD.INSTR.NO. DA
WORK TO HOUSE SEWER $3.00 f (may
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL. $5.00
Q�
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPO!�AL SYSTEM @ $3.00 STATEENCROACHMENT
MANHOLE PERMIT NO.
$7.00 LLJ
INDUSTRIALCL-
WASTE APPROVAL -_k_" 61001()
OVINER'S PERMIT3 00 CHARGES
AUTHORIZATION I TOTAL FEE '14�' 0�" CONNECTION CHARGE FEE --------------
I HAVE AT THIS DATE A CONTRACT W I TH 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
OWNER OR NEW HOUSE SEWER ✓
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS
BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY AND/OR DRAINFiELD
WITH ALL COUNTY ORDINANC E5
AND STATE LAWS REGULATING
PLU Me ING AND SEWERS. CESSPOOL ❑ DRYWELL
IHEREBY 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
CALIFC,RNIA OR THAT I AM THE LEGAL OWNER Or. AND INTEND TO DISCONNECTPLUG AND
RESIDE IN. THE ABOVE DESCRIBED RESIDENTI PROPERTY- ABANDON HOUSE SEWER
OUSESEWER
SIGNATURE
BACKFILL SEPTIC TANKS ❑
OF Piwmr;TE
SEEP.PIT(S) [I CESSPOOL
VALIDATION CK. M.0. CASH