HomeMy Public PortalAbout5313-5315 VILLAGE CIRCLE DR_Sewer__ 16A 642D - CE808 - 9/73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FDEfSS-
OR
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FOR APPLICANT TO FILL IN
LEGAL
DESCRIPTION LOT NO. OWNER
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MAIL
TRACT _ ADDRESS �_ w
V
O. OF SLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS ,i "_' y,,/`. DISTRICT NO. GROUP ®K MAP P, .,.Pft9t55 ED BY
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CONTRACTOR .._.�.>*'; ttom. _
ADDRESS � a CONNECTION DATA
L'"'• aC STATION1:.`'���! DEPTH +'
CITY -� TEL. NO. t"r � "'jx" .;
STRTE _ LIC r` MANHOLE REFERENCE `_` ^
LICENSE NO: GLASS 7 �'
NO. DESCRIPTION WORK FEE -"TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TOY. CURB P.L. M.L.TO P.L.
PUBLIC.SEWER 0 $7.00 p.C.NO.
SEPT%C TANK,SEEPAGE PIT OR -= JOB
PITS AND/OR DRAINFIELD @ 590.00 CO.IMP.NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wA1Y[E EAS[NINT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD L 01
EXTN.,CESSPOOL,DRYWELL. 0. $5.00
ALTER,REPAIR OR ABANDON HOUSE
HWY.OR ST,WIDENING
SEWER OR DISPOSAL SYSTEM 0 $3.00 O
STATE ENCROACHMENT
MANHOLE $7.00 PERMIT NO. W
INDUSTRIAL d
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��+ WASTE APPROVAL
OWNER'S PERMIT 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 . 'CIPUBLICS W - APPROVALS DATE INSPECTOR'S SIGNATURE
SI NED _DAY OF Y- 19 - —
O OR NEW HOUSE SEWER
OWNERS AGENT ��
3 CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PITS)D
AND/OR RAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY � --
WIT I.1
ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLV MBING AND SEWERS. CESSPOOL ❑ DRYWELL ED
I H BY`L IR,TIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LIG SED AS REOUiRED 8Y LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CAL CR NtA OR THAT I AM THEIEGAt O OF, AND INTEND TO DISCONNECT PLUG AND
RE51D - THE A OVE DESCRI D R at ENT AL PR.S9P (tY.
�. ABANDON HOUSE SEWER
SIGNATURE ''• 'j
BACKFILL SEPTIC TANKS
bM OF PERMTTTE / — -''� SEEP.PIT(S) ,FJ CES�PUOLS ❑
VALIDA'T'ION CK. ' M,O. CASH