HomeMy Public PortalAbout5332-5334-5336-5338-5340 VILLAGE CIRCLE DR_Sewer__ 16.A 642.0 - CES08 - 9/73 APPLICATION FOR PERK f I-
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COUNTY OF LOS ANGELES SEW R-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION eU1LDiNG
ADDRESS
LOCALITY µ .�
NEA REST ma.,.
FOR APPLICANT TO FILL IN CROSS 3T , t l
LEGAL
DESCRIPTION LOT NO. J_ OWNER -
s
«� ,�'`� MAIL
TRACT ;7 �' ADDLES
9...e�°
NO. OF BLDGS.
SIZE/OF L07 NOW ON LOT CITY TEL, NO.
U5E OF
BUILDINGS / ,y� ,!
DISTRICT NO.. GROUP MA.P -�R OCE 55ED BY
�' z.¢. , �-'�T°✓'`�.._.--a� BOK P9 `'a
zONTRACTOR ^~ •,-...:. - ,. p, .•" t '"4 ,._�,F ep -�J + ,... ;> f
ADDRESS ,�/q. rsg- CONNECTION10
- --bt- p,E STATION 7"�' _ DEPTH
CITY TEL. NO. C.+' / ➢' �,
UPPER
STATE LIC .� MANHOLE REFERENCE �r p Jtp dl-
LICENSE NO.. °' � CLASS • li f
NO. DES-CRIT N F k FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO -- Y.�,.- CURB P:L, M.L.TO P.L.
PUBLIC SEWER @ $7..00 d,;' I`�-'
SEPTIC TANK.SEEPAGE PIT OR P.C.NO
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP,NO. JOB.NO.
r? yt
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG,OR AFFfDAVIT wRIVEE CASE NEXT R€CORD.INSTR.NO. .DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD O
EXTN.;CESSPOOLDRYWELL. @ S5.00 �� U
ALTER,RE?ASR OR ABANDON HOUSE
HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM 53.00 _ STATE ENC ROACH MINT
lAAN!lOLE. 0 $7,00 PERMIT.NO. U
---- ----- INDUSTRIAL L-
WASTE APPROVAL co
CHARGES
OV mws PERMIT S .*
g�UTH PM 7�a Nq T CONNECTION CHARGE FEE
L'!V L i3�illlal'►L 1®11t TOTAL �+F. " .-.. � _
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIBURSEMENT FEE
M
TRACTO T[s CONN CCT THE ABOVE D C IBEQ EXISTING DWELLING APPROVALS
TO T! PU BLtC SEW k - DATENSPECTOR`S SIGNATURE
SIG ED THIS -DAY OF 1 �p
OWN T3 - 1 NEW HOUSE SEWER
OWNERS AGENT --- -
_ CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC:TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
qN0 STATE. THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING rr-YY
PLUM "' ND SEWER5. CESSPOOL ClORYWELL La
1 Hf
EBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICEN 'D k3 REQUIRED' BY LOol..AJL -l�
TY AND $4'ATE OF SEWAGE DISPOSAL SYSTEM
CA LtF'Cw IA OR THAT 1 AM TH OF, AND NTEND TO RES}DE IN, 77
THE A VE DISC BOFA RO RTY. DISCONNECT PLUG AND�,: ABANDON HOUSE SEWER
SfGNATURE "=,� - _ fig
OF PFlQMTTT BACKFILL SEPTIC
TANKS Q.
.CSTEEP,PIT(S') ❑ CESSw OLS ❑
VA 1J'®i) CK,..,. M.0. CASH