HomeMy Public PortalAbout8610 ROCCUS LN_Sewer__ :E4a.' a3
sA6aQ APPLICATION FOR PERMIT '
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COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
-BUILDING AND SAFETY DIVISION a1. ._ r c
IOI?N A. LAIYI$ZE. County Engineer _ ��=�';✓___ (� �_-�-=_� ,.r,_-� �'.r�'-s..�___
WILLIAM A. JENSEN, Sup't of Building
LOCA(srt
FOR APPLICANT TO FILL IN CROSI';_ T
LEGA L
OESCH T ON LOT NC ^^w OWNER }. �_ / �.• i J
MAIL
BLOCK TRACT / l "f ,,lf _ .-._ ADDRESS
NO. OF BLDGS.. ) 1 f
SIZE OF LOT NOW ON LOT CITY f TEL. NO.
6UIkOINOS
D15TRICT NOGROUP MAP PROCESS-Ly BY
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IIK
CONTRA .TOR �F -/�1 '.:i ffti\ �- •-mayT ..i Jim �' -.: _ ,�
ADDRESS ;' ` -; _ CONNECTION DATA
CIrY1 r .,'TEL NO �' STATION ,r
_.,ak r .. DEPTH
.-�, j—�. -STA TE MANHOLE REKERE NCE 'I REGISTRATION NO. —1 - ',y, .. COUNTY
_=T— L1 f,., LOWER
NO. DESCRIPTION OF WORK rEE -----------.___ ..-- _,r--- --t-._-- - --�f--__. ..----
TYPE OF CONNECTION LENGrH FROM
f(.r HOUSE SEWER CONNECTING TO y A ��.. Y. Cil RB rp L 'r - M.L.TO PJ..._ ___-_
4.1E SEWER $5.00 I "„ CL
PUBLIC
-' ----t-I= P.C.NO r'
5EP71C TANK.SEEPA F P5T OR J
PIT AND Oft ORA..NI-IELD @ 310.00 CO. IMP.NO. P�' r �' ;'_ 0
HOUSE.SEWER C"ONNECT(NG:TO J TRJNK PERMIT NO. ROAD PERMIT NO.
--CR VA'TE DiSPOSAL SYSTEM 5"3.00 wOONMEL_ADDIT_)ONAL_B—DG. AV_TWAVER
EASEMrHT RECORD.INSTR.NO.T L'A'fE
__�'WORK TO HOUSE SEWER
OVERF'CE SPOOL DRW EL6,MA NHIO LE @ $5,00
EX
_...:I _— _.... ._— HWY.OR ST.WIDENING
•ALTER,.REPAIR OR ABANDON HOJaE
SEWER OR DISPOSAL SYSTEM @ 33.00
STATE ENCROACHMENT
PERMIT'NO.
INDUSTRIAL
•(��+ �e WASTE APPROVAL_
O��}tlI�iVLRE►7 PERMIT $� —^2 --_—_. __ .CHARGE u__
CONNECTION CHARGEFEE
AUTHORIZATION TOTAL-FEE -- - i 6, - - -- --- ----- ---_ ---
'I HAVE AT THIS DATE: A CONTRACT WITH THE HEREIN NAiM.ED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWEL(.ING ---- -- --- ---------- ---- -----
TO THE PUBLIC SEWF,,R. _ APPROVALS DATE I INSPECTOR'S SIGNATURE:
SIGNED THIS ---
OWNER OR NEW HOUSE SEWER _
OWNERS AG"ENT �,Z—:.
y- -
CONNECT ADDITIONAL t
BUILDING OR WORK I
ADORES5�_
- -- -- -- SEPTIC 14N K.SEE?,PIT(5)IH HEW BY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLCAT'ION AND/OR DRAINF'!ELU
AND TATE THAT THE ABOVE 15 CORK QCT AND. AGREE TO COMPLY - -.--- .----.—_ q-.—_----___—_—
WITHLLL COUS..NTY ORDINANCES ANSTATE LAWS RLGULATING -- --_--�
PLUMBING ANC+ SEWERS. CESSPOOL ❑ DRYWE:LL ❑
I HEREBY 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
CA LiFORNIA OR THAT AM THE LEGAL OWNER OF, AND INTEND YO DiSCONNECT PLUG Ak_� _ --��—--_!----_—��--'—
Rc`S.OE [N, T'HEABUjlE"D'€&v.:RfBxO RESIOEN-f IAT„-'T=R?PERTY,
ABANDON HOUSE SEWER
SIGNATURL
„� -.f _ : L
KFiSEPTIC TANKS ❑
QF PERMIr7cE 1 F"' __ EIA( ry I
_ SEEP,PIT{SI _._ CESSPOOLS
VALIDAfiION ROBERT A, WOOD
SUPERVISING MECHANICAL ENGINEER
C K.f' M.O. CASH
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