HomeMy Public PortalAbout5245-5247-5249-5251-5236-5255 VILLAGE CIRCLE DR_Sewer__ ck 17
6A5420 - CF808 - 9/73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOs L
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEAREST
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FOR APPLICANT 70 FILL IN . w�
LEGAL {
OE5CRiPTION LOT NO. OWNER_
MAIL } ,
BLOCK TRACT ADDRESS
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT U TEL. NO.
USE OF -'
BUILDINGS DISTRICT N0. GROUP MAP pR ESS D BY
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CONTRACTOR jT
ADDRESS ,' -+. - CONNECTION DATA
STATION T) J :: DEPTH
CITY TEL. NO. v'"e e rra.�;'
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ST'ATE LIC MANHOLE REFERENCE -'cII UPPER
_
LICENSE NO; LASS v _g F ! f i. -' ._-oyoaf--
NO. _!IEVRlftiTIOAI OF WORK FEE TYPE OF CONNECTIONLENGTH FROM
HOUSE SEWER CONNECTING TO Y./' CURB P.L. M.L.TO P.L.
tPUBLIC SEWER $7.00 P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR % (.1`
PITS AND/OR.DRAINFIELD @ $10.00 CO.IMP.NO. JOB NO. 1r
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3,00
CONNECT-A ITIONAL BLDG.OR AFFIDAVIT I Wlm.I .......T RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER '@ $3.00 1
OVERFLOW SEEPAGE PIT,D R A I N F I ELD J I d
EXTN.,CESSPOOL.DRYWELL. $5.00 i v V
HWY.OR ST.WIDENING
ALTER,REPAIR OR ABANDON HOUSE TT-- -
SEWER OR DISPOSAL SYSTEM _ a $3.0_0 CD
STATE ENCROACHMENT
MANHOLE^-- 40 $7.00 PERMIT NO. _ tU
-- ----- INDUSTRIAL CL.
WASTE APPROVAL en
O♦!1\LR,S pEI�I�IIT $ 3 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE --
IHAVE AT THISDATEA CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTINGDWELLING --
TO tpYE"?USLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIL'NED THIS DAY OF ` 19,
OyV+ryER OR s"`�- ' 4p NEW HOUSE SEWER
OW r�i.Gls-RP>ENT CONNECT ADDITIONAL
- � s BUILDING OR WORK
.ADDRESS r�
f, SEPTIC TANK.SEEP,PITS)
1 HEREBY A .KNOWLEDGE THA'"M HAVE READ THIS APPLICA ION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING n
PL e}NG ANp SEWERS. CESSPOOL ❑ DRYWELL 0
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LI ENSED AS REOUIREO BY LOS ANGLES_ NTY AND STATE OF SEWAGE DISPOSAL SYSTEM
C LIFCdi NIA OR_IZH*p 1 AM T : LEGAL Q'W NER F AND ! END TO DISCONNECT PLUG AND
RE -'filE A VE DES Ri BED TIAL P P T... ABANDON HOUSE SEWER
SIGNATURE - d,! ,f, BACKFILL SEPTIC TANKS I❑
OF PEit M4Tf7`EE ,B SEEP,PIT(S) ❑ CESSPOOLS
VA l'>6TION CK, M.O, CASH
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