HomeMy Public PortalAbout5301-5303-5305-5307-5309-5311 VILLAGE CIRCLE DR_Sewer__ c 3
76A 642 — CE808 — 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 FILL IN ICROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNERpd:ae
BLOCK TRACT MAILADORE ✓' 1
NO. OF SLOGS,
SIZE OF LOT NOW ON LOT ') CITY TEL. NO,
USE OF
BUILDINGS DISTRICT NO. GROUP I MAP 'PROCESSED BY
,�,jj B lj PS
GONTRACTO�R ----_._ _ ' 1 1
ADDRESS CONNECTION DATA ?
STATION DEPTH
CITY TEL. NO.
STATE LIC UPPER
MANHOLE REFERENCE
LICENSE NO, � GLASS - LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER ® $7.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO.
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 AFFIDAVIT I WANE* IASININT RECORD. INSTR.NO. DATE V
WORK TO HOUSE SEWER @ $3.00 LLj
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL, $5.00 ►jam
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING r
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
MANHOLE @ $7.00 PERMIT NO.
INDUSTRIAL C
WASTE APPROVAL
{���.p w
OWNER'S PERMIT S 3 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF _19—
OWNER
9_OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
1 HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINFIELD
ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WIT HALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFC'RN IA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. il ABANDON HOUSE SEWER
SIGNATURE - BACKFILL SEPTIC TANKS ElOF PERMITTEE IN ❑
"— SEEP.PIT(S) ❑ CESSPOOLS
VALIDATION CK. M.O. CASH