HomeMy Public PortalAbout5322-5326-5328-5330 VILLAGE CIRCLE DR_Sewer__ 76'A 60.20 -"CE908 - 9/73 r �
APPLICATION FOR PERMIT `
_
COUNTY OF LOS ANGELES _'E e4&-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONBUILDING
ADDRESS =,f
LOCALITY cl
1
NEARE
CROSSES
FUSF�OF
R APPLICANT TO FILL IN _
G
L07 NO. OWNER
p y MAIL
ADDRESS
ImokleIll-5
NO. OF HLDGS.
yr
NOW ON LOT CITY TEL. NO.
BUILDINGS - �:- - 'a�,.-^'`�. DISTRICT NO.. GROUP MAP PRaA ESSED BY
/BK / P
CONTRACTOR
ADDRESS - ,.�- CONNECTION DATA
STATIONM' > f..
CITY TEL. NO. DEPTH
.�� J� q'� .} �
y UPPER
LICENSE NO; �' CLASS ;` MANHOLE REFERENCEt7 -;;t + l .
No. DESCRIPTION F O K FEE TYPE OF CONNECTION LENGTH FROM w
HOUSE SEWER CONNECTING TO ) -� Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER 0 $7.00 % -
SEPTIC TANK.SEEPAGE PITOR JOB NO f�
PITS AND/OR DRAINFIELD 60.00 CO.IMP.NO.HOUSESEWERCONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00
CON NEGT ADDITIONAL BLDG.OR AFFIDAVIT WAIVEtt EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.,CESSPOOL.ORYWELL. $5.00 '-HWY.OR ST.WfbENiNG
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM $3.00 _ STATE ENCROACHMENT O
MANHOLE $7.00 PERMIT NO. LUtl
--- - -- INDUSTRIAL
WASTE APPROVAL
CHARGES 'r
OWNERS PERMIT s }
+ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRAC R„TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING — APPROVALS
T HE Pl'T'51,IC SyR. ,y(,�' �p DATE INSPECTORS SIGNATURE
S NED TH15'. d.. pAY OF3_\t_. 9 --
OWNER OR 7 �' NEW HOUSE SEWER
OWNERS AGEN� .✓ .� 1 r .l" !d > --"
/ CONNECT ADDITIONAL
ADDRESS /�� BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
I
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
P I SEWERS. CESSPOOL ClDRYWELL []
i HEREBYE'E RTIF'Y THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LENSED AS REOU IRE' BY LO5 ANGLES NTY ANgeSTATE OF SEWAGE DISPOSAL SYSTEM
C. IA OR THAT I AM THE LEGAL NE)YOF, A ,+)NTESJD TO DISCONNECT PLUG AND
RESIDE 1N, TH ROVE DE^�P,RISED TIA P, RTY.. !k. ABANDON HOUSE SEWER
—_ _—
SIGNATURE . BACKFILL SE.'PTIC TANKS ❑
OF PEFIMTT. - �'w
SEEP.PIT(S) ,L-j CESSPOOLS ❑
VAIMATION CK. M.O. CASH
b 9 G l tJ
I �
`tA wt
b.,i'