HomeMy Public PortalAbout9226 ROSEGLEN ST_Sewer__ 5 A Au"6 tt•Se APPLICATION FOR PERMIT
DMSION OF BUILDING AND SAFETY SEWER--SEWAGE D 1 S PO"L
D%-run.nt of Co—tr Enginm
Cc" of Los Anal" FAD
ING
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JOHN A. L.AMBIE. COUNTY ENGINEER Eff17 CASSATT D. GRIFFIN, BUF"T of BUILDING LITY tem IB CIFOR APPLICANT TO FILL IN R �. wrInitas
DESCRIPTION
LEGAL 13 owmER WAber - -
LOT X0. (��y.,
L MIL
BLOCK TRACT ADDRESS72 g IO i k3an Gft�bidel $lam
NO.OF BLDGS. 2 CITY TEL. X0.
SIZE OF LOT NOW ON LOT
USE
BUILDINGS Dnze DISTRICT NO. GROUP YAP
CONTRACTOR PG
ADDRE53 ox CONNECTION DATA
CITY B TEL, Np. 8U24
STATION V r EPTN
113613 MANHOLE REFTREIICE YO UP
REGISTRATION NO.. WE
No. DESCRIPTION OF WORK FEE
'HOUSE S�1I Eat CONNECTING TO TYLE OF CONNECTIO .LENGTH FROM
PUBLIC 1lEW IZ >(9.50 Y• CU .L. M.L.Ttl P. .
8EPTIC TANK,SEEPAGE PIT OR
PITS AND/ORD INFIELD 3.00
OY OW SEEPAGE PIT,DRAINFIELD
EATA., POOL,DRY]IEL ANHOLE 2.00 Cd. IMP. NO.
NOUSE SEWER CONNECTING TO
`
PRIVATE DISPOSAL SYSTEM e j 1.00 TRUK P4RMrr N0. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR ITATE ENCROACHMENT
W K TO HOUPE SEWER Q s 1.00 PgRMIT NO.
ALTER.REPAIR OR ABANDON HOUSE INDUSTRIAL
SgWER OR DISPOSALSYSTEM Q� 11.00 IVAS'fH APPROVAL
_ CHA"ES `
I
CONNECTION CHARGE FEE
OWNERS PIDMTT ;i 1 00 REIMBURSEMENT FEE
AUTHORI7.A71ON TOTAL. FEE
I HAVE AT THIS DATE A CONTRACT-WITH THE HE"ll NA. D CON- APPROVALS DATE INSP R' SIGNATURE
TRACTOR TO CON ET
THE ABOVE DESCRIBED E)I.TINq DIIFLLING
TO THE PUBLIC SEWER. NEW HOUSE6EfER. _
SIGNED THIS7•��77 DAY OF 19QOXNECT ADDITIONAL.
t
ONER OR 1„e* UILDING OR WORK-
OWNERS AGENT SEPTIC TANK,PEEP,PIT(y)
ADDRFft AID/OR ORAINFf LD
I HEREBY AC-KNOWLEDGE THAT J HAVE READ THIS APPLICATION CE68PPOL El pRY�ELL[IJ1ND SrAT8 THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEIFAGE ISp, SYSTE
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DI/CQNNECT PLUG
LICENSED AS aEgU1RED BY Ldp AND
ANGELES CQUNTY AND STATE QF � X HOUSE SEWER
CALIFORNIA OR TH T I /IM THE ,LEGAL ON OF THE ABOVE
I)ES•CRIBED RE5IBEN PROP I BACKFILL SEPTIC ANKS❑
SIGNATURE ffrLEP.PIT(S)Q CESSPOOLS❑
OF PERYI
JOHN A. L4MBIE. COUNTY ENGINKErt VALIDATION ROBERT A.WOOD,CHI"PL.!90. INHPECTOR'
CX.�2 1. 4 0 19 n 4-50 2