HomeMy Public PortalAbout5208-5210-5212-5214 VILLAGE CIRCLE DR_Relocation__ 76A 6420 - CE808 - 9/73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FADDRESS
FOR APPLICANT TO FILL IN
LEGAL /
DESCRIPTION LOT NO - OWNER ' .
MAIL
BLOCK TRACT ADDRE911
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF BK
BUILDINGS DISTRICT NO. OROUP MP3 RAP pOCE55 BY
3
GONTRAC70R. -J — L-
ADDRESS - - - CONNECTION DATA
STATION "`• DEPTH
CITY TEL. NO.
STATE .. LIC MANHOLE REFERENCEUPPER
LICENSE NO. i CLASS - - LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM ^y°
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. ..
PUBLIC SEWER 0 $7.00
P.G.NO. - -
SEPTIC TANK.SEEPAGE PIT OR JOB NO.
PITS AND/OR DRAINFIELD Q 510.00 CO.IMP.NO,
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. y.
PRIVATE DISPOSAL SYSTEM 53.00 p_
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIYII IAIIMINT RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER $3.00 CJ
OVERFLOW SEEPAGE PIT,DRAINFIELD Lu
J
EXTN.,CESSPOOL,DRYWELL, :3.00
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING LL
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT a
MANHOLEPERMIT NO.
$7.00 INDUSTRIAL 0
T��.
WASTE APPROVAL CHARGES
CL.
OWNER'S
NER'S pEImrr s 3 00
I_
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 1 .
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED �D/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFCR!41A 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 BACKFILL SEPTIC TANKS ❑
OF PEft MYiTEE
" SEEP.PIT f51 ❑ CESSPOOLS ❑
VALIDATION CK. M.O. CASH