HomeMy Public PortalAbout8624 ROCCUS LN_Sewer__ �E808 (0-63
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APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DiSF'®SAL
DEPARTMENT OF COUNTY ENGINEER
-BUILDING AND SAFETY DIVISION uILDING
IOi-IN A. I:AMBIE, Coixn!y Engineer ADDRESS
WILLIAM A. JENSEN, SuP'I of BuildingLOCALITY
CROSS'ST
FOR APPLICANT TO FILL IN _-- _
D
ESC RIF ION LOT NO `� OWNER �,;._ ° ti/,✓ �:` /fit
} MAIL
BLOCK
TRACT .,+r _r. �" ADDRESS
-BLOCK
NO. OF SLOGS.
S'tE OF LOT NOW ON LO'T ' CITY Z. TEL.,. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUIL
DING$ SK PG
CONTRACTOR +,s -
__.._--. —�c_._:y:.-_•_ - +rte__—.__- _
ADDRESS ra �;, J+ �� �' _ f- . CONNECTION DATA
STATION _ '✓ ._DEPTH
CITY - I. —
/'.' r'I STATE `- UPPER
REGISTRATION NO. / �! -- COUNTY MANHOLE REFERENCE
NO.�— 'ESCRI P?IC1'r 4F WORK FEE N _ _ TYPE OF CONNECTION -_^--� LE Gr}{F'ROM
HOUSE SEWER CONNECTING TO — � j � Y. CURB ✓P L. M.L.TO P.Lj
-;.P U113 I,,,I C 5 E W E R @ $5.00 i,i. --- -:{--,-„
SEPTIC TANK,SEEPAGE,PIT OR P C,NO >'
. -
CO, IMP.NO_ '"
P!,US AhiQ/OR ORAINPIELD $10.00 -
_ —t..— ..
ti•§C5E SEWER COPiNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3-00 I ___
_ T.z O
CON'v ECT ADDITIONAL BLDG OR AFFI.DAYIT i WAIYSA EAS EMEHT RECORDINAl.. S R NO ��[> y...,
JV ORK TO HOUSE SEWER S3,00 f „
6
4 ERF LOW SEcPAGF.PIT,gRAINF±ELD-- -- .— _ A•�
EXTN.,CESSPOOL,DRY4'VELL.MANHOLE ' $5 00
ALTER,RFPAIR OR ABANDONHO USE .Y HWY.OR 5T,WIDENINGS
SEWER; R ODISPOSAL 5Y5'TE M@ $5.00 I__-__ STATE ENCROACHMENT .
.__ _, --f----T
PERMIT NO,
INDUSTRIAL
SII WASTE.APPROVAL
- iJ.---- CHARGES
OVMER`S PERMIT s 21 Oo ------ --
AUTHORIZATION TOTAI. FEF.. �!�-!'; CONNECTION CHARGE FEE
.1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- RE IMBURf;.E.MEPiT■FgEE I@
TRACTOR TO CONNECT THE ABOVE DESCRIBED EX1..371NG DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR 5 a GNATU RE
OWN THIS fi ,DAY OT° , —�... s9
NEW HOUSE SEWER '
OWNERS AG'EIVT x' / r - �_' -- CONNECT ADDITIONAL
• BUILDING OR WORK _�..-
ADORES',i_-_ -_� _.__.___ SEPTIC TANK,SEEP,PIT(S)~`�fi
I HEREBY ACKNOWLE,CE THAT I HAVE READ THIS APPLICATION
AP2DI OR DRAINFIELD
ANO STA,TE. THAT T7!E ABOVE 15 CORRECT AND AGREE TO COMPLY _-.--_-.--.�-._------------.-L----
-_
WITH AL-L COUNTY ORDINANCES ,AND STATE LAWS' REGULATING
PLUML NG ANO IEW RS. CESSPOOL [I DRYWELL ❑
I HEREBY `CERTIFY THAT I AM :PROPERLY REG!STE.RED AND/OR ALTER.REPAIR,SEWER OR j
LItENSE0 AS REQUIRED BY LOS ANGLES COUNTY AND STATE, OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND iNTEND TO DISCONNECT PLUG ANO
RESIDE IN; THE.ABOVF, DE$L'R1 BED RESIDENTIAL PdOP�c F37Y. ABANDON HOUSE SEWER
SIGNATt:RErl----7-__
OF PER MiTTEE - �. BACKF LL SEPTIC TANKS tJ
x--4 ---,c-_.-- SEEP,P.T(5) CESSPOOLS
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
/.CK. M.O. CASH
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