HomeMy Public PortalAbout8625 ROCCUS LN_Sewer__ �tf
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sasa2'D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
6tPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION B !LDINc �. u
A,URE SS
JOHN A. LAMBIE, County Engineer -
WILLIAM A. JENSEN, Supt of Building
LCCA!_TY
NEARESY
FOR APPLICANT TO FILL IN CROSS ST ^�
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LOT NO d' i' OWNER
DESCR!PT'ION
MAIL
BLOCK TRACT ADDRESS
N.O. OF BLDGS. ) y �.
SIZE 9E LOT NOW ON LOT ;( C!TY �+� TET_. NO.
BUILDINGS - i DISTRICT NO. GROUP MAP PRC>CESSF_D BY
_ _ -_ _.�.._� __... _-_---._.- _ _._�.^ _.___ ___ BK PG
CONTRACTOR � ..- -�-- ` ,rte -s__ �' �' V - •4i.
ADDRESS ,& `� J s .1� .! d CONNECTION DATA_,,.— _
i ! STATION �, '. - DEPTH
CIT
t' Y TE NO. .'^
- ;__— :- w/J z : -- } - w -- -- _ — -"— P
d3'TATE tip R
MANHOLE REFERENCE M'' ' - -
R_GISTRA !ON NO. g "l „_ LJ COUNTY '
NO. C.,ESCR!PTICON 11F WORK FEE TYPE OF CONNECTION LENGTH FROM
Ii Ol1�E5EWER CONNECTING TO hl-fit $- Y. CURB P L M.L.TO PfL. J � --
ai„
PUBLIC SEWER @-s-5..00 _
---.,-7.SEPTIC,,TANK,SEE CO.OR - i '' O �} r
PITS AND/OR DRAINFiELD @ 810.00 CO_IMP NO. _...
I
r rIGUSE
SEWER C:ONNEC"TING TO TRUNK PYRMIT NO. ROAD PERMIT NO. ix
---_ FRIBA TE DISPOSAL SYSTEM @ $3.00
._wAiv_ ._- Ri OD. NST_R-N.OT_-._D-A.__ECONNECT ADDITIONAL BLDG,OR AFFIDAVIT FAE
WORK T: HOUSE SEWER $3.00
J i
OVERF-i.OW SEEPAGE PiT,DRA.N FIELD i J___,__,..-..�- •
EXTN..,CES FOOL,DRYWEI..L.MANHOLE 4 $5.00 '
HWY,OR ST.WIDENING
ALTER.RF PAI,?OR AB4 NOON HOUSE z
SEWER.OR DISPOSAL SYSTEM _@_S3.00 - ---_- __-.__
STATE LNCRUACHMENT _M
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
-__._--__. ____._.__-_ _,__. __ 1____.._ CHARGES
OWNER'S PERMIT 21 00 ---- — --- - - ---- ----- -
- - -
CONNECTION CHARGE.FEE
AUTHORIZATION TOTAL FEE ----- __--- ---
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
REIMBURSEMENTFEE
TRACTOR "TO CONNECT THE ABOVE DESCRIBED EXiSTiNG DWELLING --- /�yy-- -'�--T--'---�- -'- -'_ --
Y6 THE PUS 1.IC SEWER.:. APPRO Y ALS DATE INSPECTORS SIGNATURE
SIGNED THIS— DAY OFF-
OWNER OF, /' I = NEW HOUSE SEWER
OWNERS kGEf•1T. _=_r''- CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS __ ' -
.- _.._. _ ____-__..- SEPT)("ry'ANK,S'EP,F'!"t'(Fi)
I HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION AND/OR DY.AINfIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL CO:INTY ORDINANCrLS AND STATE LAWS REGULATING !
PLUMB NG AND SEWERS. CESSPOOL F. DRYWELL ❑
I HEREBY CERTIFY THAT 9' AM PROPERLY REGISTERED AND./OR ALTER,REPAIR. EWER OR �
LICENSED A$ REQUIRED BY LOS ANGLE COUNTY AND STATE i SEWAGE DISPOSE SYSTEM
CALL f'ORt77A OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PL.i1G AND I
REST DE tN. THE ABOVE DESC Ri3ED RESIDENTIAL-_:ROPERT'Y. ABANDON HOUSE SEWER
SIGNATURE
BACKFILL SEPTIC TANKS
1
OE:.F' PERMITTE �
SEEP,PIT(5) ❑ C.cSSFOOLS
VALIDATION ROBERT A. WOOD
CKM.O. CASH, SUPERVISING MECHANICAL ENGINEER
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