HomeMy Public PortalAbout5300-5302-5304-5306 VILLAGE CIRCLE DR_Sewer__ '6A 642D - CE808 - 9!73
APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS".,'}]?,'t C"
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST,
LEGAL 7
DESCRIPTION LOT NO. OWNER ! ,)
+ MAIL
t �RACT y.^t ADDRESS
O. OF SLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
US OF _ -/ -
USE(ONGS - L-+[G1,/�'p DISTRICT NO, GROUP MAP P-47SED BY
BUILDIBK P3 fi
CONTRACTOR
ADDRESS s �o'(` CONNECTIO DATA
STATION ,�'/ S DEPTH
CITY TEL. NO. on^
STATE -- LI �! 1 UPPER
< // MANHOLE REFERENCE /--
LICENSE NO '- o-'- 4'
GLASS t ���✓; �a � "' ��e r'{(r. '1"��
No. D GRIP ION 6F WbRK FEE TYPE OF CONNECTION LENGTH FRO
HOUSE SEWER CONNECTING TO Y• CURB P.L. M,L.
TO P.L.
PUBLIC SEWER @ $7.00
SEPTIC TANK,SEEPAGE PIT OR P.C,
JOB NONO. �_ y
Co.IMP.NO. . ,/ --
ITS 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 I WAIVER EASF M[MT RECORD.INSTR-N07F DATE r
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD O
EXTN.,CESSPOOL.DRYWELL, $5.00 V
ALTER.REPAIR OR ABANDON HOUSE - HWY,OR ST.WIDENING
SEWER OR DISPOSALSYSTEM $3.00 _ STATE ENCROACHMENT O
MANHOLE $7.00 PERMIT NO. LV
-- -- INDUSTRIAL c-
WASTE APPROVAL Z
OWNER'S PERMIT —_-'- $ - CHARGES
:,
CONNECTION
AUTHORIZATION CHARGE FEE TOTAL FEE '
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING —
TO THE PUBLIC SE R. 1 APPROVALS DATE INSPECTOR'S.SIGNATURE
SIGNED THIS DAY OF
WNER NEW HOUSE SEWER
tlWNERS AGENY J
." CONNECT ADDITIONAL
ADDRESS." BUILDING OR WORK
/ _
SEPTIC TANK.SEEP,PIT(S)
IHEREBY ACKNOWLEDGE THAT I' �AVE READ THIS APPLICAT N AND/OR DRAINFIELD
ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ------ -
WITH. ALL COUNTY ORDINANCES AND STATE LAWS REGULATING r(
PLUM ING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I SERE BY CERTIFY THAT i AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LIC LASED AS REQUIRED BY LOS ANGLE�.COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALI I AM THE LEG /OWN R OF, "'TEND TO DISCONNECT PLUG AND
Ft
ESIDE
IN, THE AB E DES )BE l;, IA P - RTY. � ABANDON HOUSE SEWER
SIGNATURE -- '� 1-y
OF PERMTTTE Y' BACKFILL SEPTIC TANKS L1
SEEP,PITS) ❑ CESSPOOLS
VALIDATION cX. M.O. CASH
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