HomeMy Public PortalAbout5201-5203 VILLAGE CIRCLE DR_Sewer__ '6A 6420 - CE808 - 9/73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FSS
X
FOR APPLICANT TO FILL IN
LEGAL
DESCRIPTION LOT NO. OWNER
' MAIL �
BLOCK TRACT - ADDRESS ,,...ad
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT Nj0. GROUP MAP P�tOCESSED BY
_ 7 BJK�I Jj P5 j(
GONTRACTOR
ADDRESS ,... CONNECTION DATA
STATION DEPTH
CITY TEL. NO. -
STATE _ LIC UPPER
LICENSE NO, CLASS MANHOLE REFERENCE LOWER
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 0 $7.00 P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR JOB NO.
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP,NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO,
PRIVATE DISPOSAL SYSTEM @ $3.00 d.
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I N'AIV[II [AS[MINI RECORD.INSTR,NO, DATE C)
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD LLI
EXTN.,CESSPOOL.DRYWELL. $5.00 J
ALTER,REPAIR OR ABANDON HOUSE
-- HWY.OR ST.WIDENING LL'
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT
MANHOLE PERMIT NO.
$7.00
INDUSTRIAL C�l
WASTE APPROVAL
OWNERS PERMS 3 00 CHARGES W
k�
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
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(S)
1 HEREBY;:CKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL rOUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL Cl DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CA LIFCRN IA OR THAT 1 AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE - 11OF PE4?M"TEE BACKFILL SEPTIC TANKS
SEEP.PIT(S) Cl CESSPOOLS ❑
VALIDATION CK. M.O. CASH