HomeMy Public PortalAbout8622 ROCCUS LN_Sewer__ �9
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A64 i�D 0-63 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engine*x ADCREss
WILLIAM A. JENSEN, Supt of Building _
LOCALITY , r
NEAREST._—. �f- j/ - y✓
FOR APPLICANT TO FILL IN CROSS S, -�
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DESCRIPTION LOT NO f-,( OWNER
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BLOCK THAC -3-. l /F Jr / ADDRESS J
NO. OF BLDGS. ;i
--SIZE Oh LO'?' NOW ON ...0'F � CITY .�• TEL. NO,
USE OF __ —_.
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lLDINC�S 'Y•I' DISI^l'NO, GRO'J P, MAP PROCESSED BY
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CONTRACTOR �� ��y, �' �" ,��<_� �� •.. � -�ti ,� �
ADDRESS i � - l�_ � Fs' �.
�` CONNECTION DATA
STATION - y.,..- DEPTH
CITY Y: TEL NO i' `> . _.s` i ,y` / d y _
-,-.--� - — -- — J—�j -_ UPPER
tom[''-''NATE MANHOLE E REFERENCE
REG!S7 RATION NO. COUNTY
No.--r-- GESCRIPT!O_N*OF WORK FEE — TYPE OF CONNECTION LENdTH FROM —
�HOUSF.SEWER CONNECTING TO - �` I Y. CURB P L M.L.7S5 P.L,
@ S00PUeLiCh' `
P.C.NO t - CL
SEPTIC TANK SEEPAGE PIT OR -- -- ---� - /
PITS AND OR DRAINFIELD � 10.00
_ -
HOUSE SEWER CONNECTING TO� TRUNK PERMIT NO. ROAD PERMIT NO.
1
PRIVATE DISPOSAL SYSTEM $9.00 � _ ELI
PP��
CONNECT AUDI I�NAL 6LDC. OR AFFIDAVIT' wn:v.z easxxedt 1 RECORD.IN5TR-NO. DATE a�
WORK TO HOUSE SEWER @ $3.00
yOVERFLOW SEEPAGE PIT,DRAINFIELD
'EXTN:.,C€S SPOOL,DRYWELI..,MANHOLE $5.00 a-
n _4__4 HWY..OR ST.WIDENING
ALTER,REPAIR OR ABANDON HOUSE `
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SEWER OR DISPOSAL SYSTEM J $3.00 STATE ENCROACHMENT
PERWT NO.
INDUSTRIA„
WASTE APPROVAL
CHARGES
_- _—.___—_.. L—�� ®O.__
��*�O ER,. py PERMIT
AU 1HORI4ATIVN TOTAL FEE CONNECTION a;:NARCoE FEE
— �� REIMBURSEMENT FEE
'i HAVE AT 7'}1;5 GATE A CONTRACT W['fH TNF: HEREIN NAMED CON- -- - -� -
TRACTOR TC> COENE T THE ABOVE DESCRIBED EXISTiNCU OW L41NG ---- �g —y 7�+ '--i----- ---
TO THE PUBLIC SEWER// APPROVALS � DATE �1NSPECTOH S SIGNATURE
-r AY D0SIGNECTHIS —.
6WNER OR -' —�+ NEW HOUSE SEWER i
OWNERS AC;'cN __. —
CONNECT ADDITIONAL
BUILDING OR WORK
SEPTIC TANK.SEEP,PIT(5)
Ii F":BV ACMN6Wt_ED THAT I HAVE READ 'THIS APPLICATION AND:OR C.P.AINFIELG
AND STATE: ThiAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ,3 1,1. COUNTY ORL INA LACES AND STATE LAWS REGULATING 1
FL MSIN.,: ANO SEWERS. CESSPOOL DR. ELL
t HEFIERY CERTIFY THAT 'I AM PROPERLY' P.EGIST FRED AND/OR .ALTER.REPAIR.SEWER OR ---i-T---- �1— ----�—
LICENSED AS REQUIRED BY LOS .ANGLES COUNTY AND STATE OF SEWAGE D{SPOSAL SYSTEM
CA!.'F OPNIA OP 'AT f AM ?HE E 4L 04V PIER OF A '6 INTEND TO Di 5CON N EC-CT —LUG AND
RES;DE, IN T:HE A50VE ESC RI BED RES IDENTI SC�._PfCOPERTY. ABANDON HOUSE SEWER
S BACKFILL SE.GNA.Uri F.' -
-_ 1 - __ - _�.. 'PTI..;TANKS
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0F' PEr-7MITTEE - - '.a.'��s..mac_."- s EEP,PITt^a> ❑ CESSPOOLS [�I
VALIDATION ROBERT A. WOOD
..
CK. M.O. CASH SUPERVISING MECHANICAL ENGINEER
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