HomeMy Public PortalAbout5216-5218-5220-5222-5224 VILLAGE CIRCLE DR_Sewer__ iy
76A 6420 - CE808 - 9/73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING Y
ADDRESS
LOCALITY
NEAREST -
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO, OWNER
MAIL ^A.y
BLOCK TRACT ADDRESS 1.e
NO. OF BLDGS. ..�
SIZE OF LOT NOW ON LOT ¢TTY TEL. NO.
USE OF DISTRICT N0. GROUP "AAP ]F�ROIZES�.EO
BUILDINGS BK
P l"
CONTRACTOR
ADDRESS CONNECTION DATA
STATION DEPTH
CITY TEL. NO.
STATE LIC UPPERMANHOLE REFERENCE
LICENSE NO, CLASS 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 $7.00 ---
SEPTIC (ANK,SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIELD $10.00 CO.IMP. NO. -)OB NO.
HOUSE SEWER CONNECTING TO TRUNK.PERMIT NO. ROAD PERMIT NO. �..
PRIVATE DISPOSAL SYSTEM $3.00 2
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEMENT RECORD. INSTR.NO. DATE V
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD I LLI
EXTN.,CESSPOOL.DRYWELL, $5.00 'J
ALTER.REPAIR OR ABANDON HOUSE — HWY.OR ST.WIDENING Lt..
SEWER OR DISPOSAL SYSTEM Q $3.00 STATE ENCROACHMENT
MANHOLE $7.00 PERMIT NO. cC
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s 3 00 CHARGES w
AUTHORIZATION1 TOTAL FEE CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR T0C ONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLISEWER. APPROVALS 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,PITS)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE .ABOVE IS CORRECT AND AGREE TO COMPLY _
WITHALL 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 REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFCON(A 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 PFR MTTTEE -_-.�- .- SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION CK. M.0. CASH