HomeMy Public PortalAbout5257-5259-5249-5261-5263-5267 VILLAGE CIRCLE DR_Sewer__ '6P 64ZD - CES08 - 9%73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY -
NEAREST
FOR APPLICANT TO FI L IN CROSS ST.
� ► ` it ,I�
OWNER
DESCRIPTION LOT NO.
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS, TEL. NO.
SIZE OF LOT NOW ON LOT CITY
USE OF DISTRICT NO. GROUP MAP PR C�SED BY
BK PS
BUILDINGS
CONTRACT OR
ADDRESS - .__, CONNECTI N DATA
p fy STATION i DEPTH _
CITY
TEL. NO. (� lJ
LIC ' / ` ~
STATE `' `�' � � MANHOLE REFERENCE .� I �; 1-
LICENSE NO: yam, ,' GLASS ti J'J LOWER
NO. DESCRIPT! OF WOR FEE +/� TYPE OF CONNECTION Y LENGTH FROM
HOUSE SEWER CONNECTING TO t./ CURB P.L. M.L.TO P.L. Ga
PUBLIC SEWER 0 $7.00 L�� P.C.NO-
SEPTIC TANK.SEEPAGE
PIT
OR CO.IMP.NO. JOB NO.
PIT5 AND/OR DRAINFIELD � $10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 __
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE .r
WORK TO HOUSE SEWER _ $3.00
d
OVERFLOW SEEPAGE PIT,DRAINFIELD -- C�
EXTN..CESSPOOL.DRY W ELL. $5.00 -_ HWY.OR ST.WIDENING 0
AL-TER.REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM - $3.00 _ STATE ENCROACHMENT V
-- --- PERMIT NO. W
MANHOLE $7.00 INDUSTRIAL �
WASTE APPROVAL Z
_. --- CHARGES
OWNER'S PERMIT s s 00
CONNECTION CHARGE FEE
AUTHORIZA'T'ION TOTAL FEE t
REIMBURSEMENT FEE
I H E'.AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
T.
TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING AppROVAL5 DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SI NED THIS DAY OF - f
OW R OR I r /' NEW HOUSE SEWER -w--I----_
OWN NT J r,_�C CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS -' SEPTIC TANK.SEEP,PIT(S)
I
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AN STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY -------
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CESSPOOL ❑ DRYWELL ❑
PLUMBING AND SEWERS. --
1 ERE GK.t5 CEtyRTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR,SEWER OR _
LI`ENSEREOUiRED BY LO , ANGLES r,.OVFTTY AND
D STATE OF SEWAGE DISPOSAL SYSTEM
C fFCIRNIA�OF"TF(JI�T' 1 AM TH yEGAL O 'BIER AND INT 'q1D TO DISCONNECT PLUG AND
R 1N'THE AB6VE DESC BED RE +AL PROPERT ABANDON HOUSE SEWER
SIGNATUREI f f j�• _BACKFILL SEPTIC TANKS
CESSPOOLS El
PERMTTTE ! SEEP.PIT(S), 0
- .E.I� 1,
VALID TON CK' M. CASH
7 4 4 E-VIII. 3