HomeMy Public PortalAbout5317-5319 VILLAGE CIRCLE DR_Sewer__ '6A 542D - CE808 - 9173 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEARFS.T
FOR APPLICANT TO FILL IN
LEGAL �.
DESCRIPTION LOT NO. OWNER
-
MAIL
' TRACT ADDRESS
NO. F BLDGS.
R.Z:�/.F_
LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS .v-y DISTRICT NO. GROUP MAP _ %'PR-0CESS EO BY
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CONTRACTOR �jS, 1 aa(7. y .C_
ADDRESS �' C.�. I / ,>x . - y, y _ CONNECTION DATA '
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CITY �- TEL. NO. "+",ti
STATION DEPTH
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STATE yyy,,, LIC " ..7 �j "`-"'
LICENSE NO. GLASS MANHOLE REFERENCE LOWER
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NO. DESCRIMIDWOFF WORK FEE „.TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO , Y. - CURB P.L. M.L.TO P.L.
PUBLIC SEWER 0 $7.00 Z,,�J s
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SEPTIC TANK.SEEPAGE PIT OR ..�-y P.C.NO.
NO
PITS AND/OR DRAINFIELD 0 SI0.00 CO.IMP.NO.. �+
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. 7` ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIV[R I [ASK;ILKr RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER $3.00 �..
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTH.•CESSPOOL.DRYW£LL. 18 $5.00 U
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING fes,
SEWER OR_DISPOSAL SYSTEM ® $3,00 STATE ENCROACHMENT V
MANHOLE $7.00 PERMIT NO. LL!
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WASTE APPROVAL Z
CHARGES
OWNER'S PERMIT $ .
_ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE r�� -•�— --
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON• REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE P�VRL(C SEWER. A DATE INSPECTOR'S SIGNATURE
5lGNE THIS DAY OF YV 4
OWNER OR —� � c
,f NEW HOUSE SEWER
OWNERS AGENT —
,4 CONNECTADDITIONAL
BUILDING OR WORK
ADDRESS _
SEPTIC TANK.SEEP,PITS)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ANO/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL ,COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 NE E0Y CERTIFY THAT 'LOS
PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
L iCEM1F ED AS REQUIRED BY LOS ANGLES CO TY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIF RNIA OR THAT 1 AM THE LSOAL O ER, F• AND 1 'FEND TO DISCOPi NECT PLUG AND
RE51D IN B E ESCRI �REAL P PE ABAN DON HOUSESEWERSIGNATURE
OF PEIRMTTTEE_ BACKFILL SEPTIC,.IA,N K5 ❑
SEEP.PIT(S) .[— CEISSPOOLS ❑�
VALfDATnlON CK,rI M.0. CASH
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