HomeMy Public PortalAbout5200-5202-5204-5206 VILLAGE CIRCLE DR_Sewer__ 16A 642D - CE808 - 9/73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEA—REST
�.,FOR APPLICANT TO FILL IN
LEGAL ' `
DESCRIPTION LOT�N b. OWNER 1,
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS,
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS .DISTRICT NOGROB
UP MAP pROCESSEO BY
K PG
5 .r
CONTRACTOR
ADDRESS CONNECTION DATA
T STATION DEPTH
CITY TEL. NO.STATE .-
- UPPER
LICENSE NO: 'y " r CLASS _.-I MANNOIE REFERENCE LO.YY,E,R
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. _
PUBLIC SEWER @ $7.00 `
P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. JOB NO. ..
HOUSE SEWER CONNECTING TO
TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00
O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wAIVEE I EASEMENT RECORD.INSTR.NO. DATE U
WORK TO HOUSE SEWER @ $3.00 LLJ
OVERFLOW SEEPAGE IT.DRAINFIELD —1
EXTN..CESSPOOL.DRYWELL. @ $5.00 LL-
ALTER.
L
ALTER.REPAIR OR ABANDON HOUSE
HWY.OR ST,WIDENING }
SEWER OR DISPOSAL SYSTEM 0 $3.00 C
_- STATE ENCROACHMENT
0 Ll
$
MANHOLE 7.00 PERMIT NO.
—
- INDUSTRIAL 0
WASTE APPROVAL d
OWNERS PERMIT $ 3 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_,
OWNER OR NEW HOUSE SEWER
OWNERS AGENT -
�, CONNECT ADDITIONAL
ADDRESS _ BUILDING OR WORK
SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY _
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFCRN IA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE - El
PE4tMrfTEE BACKFILL SEPTIC.TANKS
SEEP.PITS) ❑ CESSPOOLS
VALIDATION CK. M.O. CASH