HomeMy Public PortalAbout5329-5331-5333-5335 VILLAGE CIRCLE DR_Sewer__ &6A 6420 - CE808 - 9l73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION su1LDiNG
LOC L17Y'
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T. z .
LEGAL
DSGRI TION LOT NO. - OWNER
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ADDRESS
NO. OF LOG'.
SIZE. F LOT&✓ NOW ON LOT CITY TEL. NO.
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BUILDINGS "" C }. '`f ✓'` „'r._:,: DISTRICT NO. GROUP $N pG MAP -PR'OCESSED BY
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477ONTRACTOR
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ADDRESS- _ CONNECTION qATA f^
STATION DEPTH
CITY i TEL. NO. r'7 - -� p
STATE t ' ,�€ LIC f~� u or MANHOLE REFERENCE ?� _e -T Lf! UPPER
LICENSE NO:. "`s"°' �' CLASS '�, ,,F, ,� 9 NF 1 +
No. DESCRIPTION OK WbRA FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TOCURB CURB P.L. M.L.TO P.L.
I
PUBLIC SEWER 4D $7.00 ... L: .J ✓'
P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD f10.00 CO.IMP.NO. JOB NO. c
HOUSE SEWER CONNECTING TO _ TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM f3.00
CONNECT ADDITIONAL BLDG,OR AFFIDAVIT WAIVER SA5QI[Mi RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER $3.00 ��
CL.
OVERFLOW E CID SEEPAGPIT.DRAINFtELD �
EXTN.,CESSPOOL.DRY WELL. $3.00 -` C_'d
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING Q:�
SEWER OR__D!_5_POSAL SYSTEM $3.00I STATE ENCROACHMENT
MANHOLE $7.00 PERMIT NO. W
---- INDUSTRIAL D-
9
WASTE APPROVAL �
CHARGES
OWNER'S PERMIT
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE -� -- --
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
7O THE PUBLIC SEW R. - DATE INSPECTOR'S SIGNATURE
SI E"'rHIS f - DAY OF - 19 --"— -
OWN fff ,i NEW HOUSE SEWER
OWNERS AGEN CONNECT ADDITIONAL
ADDRESS _ - - BUILDING OR WORK
SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE AROVF 15 CORRECT AND AGREE TO COMPLY -- .—
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING �-i
PLUMBING AND SEWERS. CESSPOOL ClDRYWELL ❑
I HE BYERTIFV THAT I AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR,SEWER OR
LICEN ED'AS REQUIRED BY LOS ANGLES COUNTY AND , TE OF SEWAGE DISPOSAL SYSTEM
CALI M �"d2NlA OR I ATHE"+. O OF, AND DISCONNECT PLUG AND
REStD E ABO E DESCR BED R -IAL pi(O TYND TO ABANDON HOUSE SEWER
SIGNATURE �' r� iy BACKFILL SEPTIC TA14.KS ❑
OF PEQMTTTEF � .." `� SEEP.PIT(S) ❑.-"CESSPOOLS ❑
VALWATION CK,j. M.0. CASH
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