HomeMy Public PortalAbout5260-5262-5262-5264-5266 VILLAGE CIRCLE DR_Sewer__ r-I
76A 6420 - CE808 - 9/73 APPLICATION FOR PERMIT ��
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS'-" I
LOCALITY
NEAREST '
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO, OWNER
L MAIL
TRACT �,.- ��v) �. ADDRESS
N . OF SLOGS.
SIZE OF LOT zOW ON LOT CITY TEL. NO,
USE OF _
BUILDINGS _ DISTRICT NO.17'Oupj
MAP �_J'•R$)CESSED BY
.'
60NTRACTOR l' � t+� � G''y
ADDRESS _ -' I CONNECTION DATA
CITY STATION '"��., 11/ ,Y� DEPTH
STATE LIC MANHOLE REFERENCE ,+� < y �
LICENSE NO, `. __ GLASS �) / �,.; i�td,. "LOWER
NO. I DESCRIPTION OF 4VCrRK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO CURB P.L. M.L.TO P.L.
PUBLIC SEWER 0 $7.00 r '- _
P.C.NO. '<
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 510.00
CO.IMP.NO. JOB NO. .�
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO, ROAD PERMIT NO.,
PRIVATE DISPOSAL SYSTEM 53.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIY wMv[[ 6A5cM[Bt RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER $3.00 Cly,.
OVERFLOW SEEPAGE PIT,DRA IN F I EL
EXT N.,CE5SPOOL.DRYW ELL, 35.00 v
ALTER.REPAIR OR ABANDON HOUSE HWY.OR S7.WIDENING
SEWER OR DISPOSAL SYSTEM @ 33.00 STATE ENCROACH MEN7 PERMIT NO. W
O
MANHOLE $7.00 -- --
---- INDUSTRIAL a
WASTE APPROVAL C/)�
CHARGES
OWNERS PERMTC S +
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE -
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT
`F� E
TRACTOR TO CONNECT THE ABOVE DESCRIBEp EXISTING DWELLING APPRO APPROVALS TO THE PUBLIC 5 R. DATE INSPECTOR'S SIGNATURE
SI NED THIS DAY OF s )9 -
ONER OR i NEW HOUSE SEWER
O NERS A - - CONNECT ADDITIONAL
,� ,. BUILDING OR WORK
ADDRESS__ - f _ SEPTIC TANK,SEEP,PIT(S)
Ill
HEREBYOEDG T T19 HAVE READ THI APPLICATI N AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLU MB ING�AND SEWERS. CESSPOOL ❑ DRYWELL
I HE BT- CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICEN ED AS REQUIRED BY LOS ANGLES CO,^ru'Y�9r AND 5 TE OF SEWAGE DISPOSAL SYSTEM
CALINIA OR nI AM THE LE 'L OW ER Qf, AND iiEN�TO RALI(�IN, AM RISE Fj11E51 P AN T DISCONNECT PLUG AND
ABANDON HOUSE SEWESIGf'y ✓.F PERMITTEEM BACKFILL SEPTIC TANKS []
— ,fir -y�.��S�EEP,PITS) E$SPOOLS
Y A A ION CK. M.0. CASH
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