HomeMy Public PortalAbout9066 RANCHO REAL RD_Sewer_1962-05-04 :E808 3-fit
CIA6a21 APPLICATION FOR PE MIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING' ,
JOHN A, LAMBIM County Engineer ADDRESS ;
WILLIAM A. JENSEN, Supt of Buflslisq LOCALITY
NEAResr
FOR APPLICANT TO FILL IN CRoss ST. '
LEGAL )
DESCRIPTION LOT NO. .a -' OWNER f
BLOCK TRACTS `f MAIL
I 3 ADDRESS
NO,OF BLDGS,
SIZE OF LOT NOW ON LOT CITY TEL. NO
USE OF
EUILDINGS DISTRICT NO. GROUP MAP PROCESSBY
BSC PG
CON
TRACTO !_ a/
ADDRESS CONMECTION DATA
CITYf°� TEL.NO. i �' Qom' STATfON DEPTH
y A 5"IATE MANHOLE REFERENCE UPPER
REGISTRATION NO. ❑COUNTY LOWER
NO. I DESCRIPTIO OF FEE
_mt: HOUSE SEWER CONNECTING TO $
PUBLIC SEWERSI- TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR T. CURB P.L. WL.TO P.L.
ITS AND/OR DRAINFIELD $$.00
OVERFLOW SEEPAGE PiT,DRAINFIELD 'y ,'k _
r
ERTN..CESSPOOL:DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO lO
PRIVATE DISPOSAL SYSTEM @ $1,00 CO., N.O, u
CONNECT ADDITIONAL BLDG.OR �_-> ---- `, ,YRUNK PERMIT NO. ROAD PERMIT NO.
WORK-TO HOUSE SEWER 3,00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT O
SEWER OR DISPOSAL S`'STEM @ $1.00
- - PERMIT N0.
INDUSTRIAL LU�
r, WASTE APPROVAL
i. '.h•I, CHARGES
OVMER`S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED 'THIS DAY OF- - 19 NEW HOUSE SEWER 1
OWNER OR CONNECT ADDITIONAL -
OWNERSAGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT S HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WIIH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTE
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY D STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM T LEGAL q NER F, THE ABOVE
DESCRIBED RESIDE P P Ts ,' BACKFILL SEPTIC TANKS Q
SIGNATURE
^ SEEP.PIT(S ❑ CESSPOOLS
V IV
OF PERMITTEEN
VAIMATION ROB5RT A. WOOD
'r CK. M.o. CASH SUPERVISING MECHANICAL ENGINEER
, I