HomeMy Public PortalAbout5248-5250 VILLAGE CIRCLE DR_Sewer__ 76A 642D - CE808 - 9173 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEAREST
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FOR APPLICANT TO FILL IN
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DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT - ADDRES
NO. OF BLDG5. .•^�''
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF D N0. GROUP MAP PROCESSED BY
BUILDINGS _ SK PS ,
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CONTRACTOR .Y r �.:
ADDRESS CONNECTION DATA
STATION DEPTH
CITY � TEL. N0..
STATE LIC MANHOLE REFERENCE - UPPER
LICENSE NO; - CLASS LOWER
No. f 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, d
PRIVATE DISPOSAL SYSTEM $3.00 �. CD
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVE[ [A5[M[NT RECORD.INSTR.NO. DATE U
WORK TO HOUSE SEWER ® $3.00 L J
OVERFLOW SEEPAGE PIT.DRAINFIELD J
EXTN..CESSPOOL.DRYWELL. $5.00 LL
HWY.OR ST.WIDENING
ALTER.REPAIR OR ABANDON HOUSE
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SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT
MANHOLEPERMIT NO.
$7.00 INDUSTRIAL d
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 3 00 r
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I HAVE 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 I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
ANO
STATE THAT TME ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REG15TERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFC,RNIA 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
OF PERMITTEE_ BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION CK. M.O. CASH