HomeMy Public PortalAbout8616 ROCCUS LN_Sewer__ &08 10-63
6A64�I� , APPLICATION FOR PERMIT �
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING ANIS SAFETY DIVISION F77.,
JOHNA. LA:MB$E. County Engineer WILLIAMA. JENSEN, Supt of BuildingCAL.Tv
NFARE T
FOR APPLICANT TO FILL IN cRD55 ST
y
LEGAL-
LOT
D_E5C_R1 TIO,ry NO OWNER
MAILi .
BL OC.Y.
TRACT `, -.J ADDRE55
SIZE OF LOT NOW 6M1 O v CITY 1 ' TEL. NO. >r?
USE OT' St RiCT N M P Y
BUILDINGS �i Di O. GROU? A PROCESSED B
y i
PG
BK
CONTRACTOR / _ _ !/ � .. ,e �-••yy ..'_t � 1`.:i —.. / �' �',. T
ADDRESS ,�' .� .'' 'J :': I x �> -,/� CONNECTION DATA - -
-'
STATION > ..., L -p rDEPTH
C(TY. -C�-'f- p'�- _-. y s E L, YO,
-ATE
REGISTRA i0\ [-C ' �'�_• CI COUN?i' MANHOLE REFERENCE ,,. *' ►
No. GE:sCRIPTION OF WORK y{ FEE _ TYPE OF CONNECTION - LENGTH FRO! r -"
HL1'�tSF,SEW CR COFdN ECT NG TO. ... r C Y. CURB •�P L •' ..L T--P L_.-
f�UBLI.0 SEW @ S .00 a .__.___.___ _.__._—_ .—___— .,.'`
._Er'TIC TANK., T
CO.IMP Nb.
I PITS AND�OK ORAiIv P'1 Et_.D f $f 0.00
�_..y
-HOUSE
E 5.Sf WEfz'--- __CTI.fV-G---- .. __—___.._ ...__—...�.—_—_. .•
CONNP TO - TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3,00 _ -- --_.__. —i P^*.
.__ WORK LOW SEEPAGE ER DRAIN FtE'I_D .— --
WAIVER EASEMENT RECORD. INST NO DATE �.
PIT
� ONNECi ADDITIONAL BLDCa OR t AFFIDAVIT I
WORK TO HOUSE SEWER `R $3.00
I EXTN CESSPOOL.,ORYWE.LL,MANHOLE 1�. $5.00
R
_ PAIR OR ABA NDON HOUSE )— .. _—__. —.— HWY. OR ST WIDENING
Wk ? 0 M OR DISP5AL SYSTEM $3.0b
_._ —— _...._ STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OW'NER'S PERMIT 21 Op -__---------- -_-- _---
- CONNECTION CHARGE.FEE
AUTHORIZATION TOTAL FEE -- - -------- -------- ------------ --
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESi'RIBED E.35TING DWELLING ----- - - -- - ^�'----'
TO THE PUBLIC SEWE�r"tV. !. APPRO ALS r, DATE i INS PFLTOR 5 51 CsNATURE
L0RkSS--
IED THIS DAY OF .r '.ice _—.�7g_:`� "------ ---- - ---" — -- --- i ---- — --
R OR v - NEW HOUSE SF ZR
RS AGENT ,.- _ -..,,Y _
"— - ✓--�r`>—' --- CONNECT ADDITIONAL 1
_M.• --t BUILDING OR WORK
SS SEP'TIC TANK.SEEP,PITS) t
FREBYACKKtC3tiVLEDGE THAT 1 HANE READ TH15 APPLICATIONAND'OR ORAtF1FtELd
TATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLYALL COUNTY ORDINANCES AND STATE LAWS REGULATINGBING AND SLWERS. CESSPOOL � DRYWELLEREBY CFRTIFY THAT . AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER ORSED AS RFQUIRED BY LOS ANGLES COUNTY AND STATE Or SEWAGE DISPOSAL SYSTEM
ORNIA OR THAT I AM THE1 GA('. ONN_R OF A dD INTEND TO DISCO, T PLUG ANDE IN, 7'HE Ad"�V'L DES R+BED R.SILENTIae-"'PRCPf:'RTY' ARANUON NOUS SEWER7URE —__—_PERMITTEE
BACKFILL SEPTIC TANKS r] f
SEEP.PIT(51 ._ C_E,55.FO6LS �1
;:,VALIDATION ROBERT A. WOOD
r • l SUPERVISING MECHANICAL ENGINEER
j CK. j M.O.. CASH