HomeMy Public PortalAbout5337-5339-5341-5343-5345 VILLAGE CIRCLE DR_Sewer__ '6A 642D — CE806 — 3!73 APPLICATION FOR PERMIT _ -
COUNTY OF LOS ANGELES SEWER—SEWAGE DI OS
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS --y-
LOCALITY �
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
—LEGAL
DESCRIPTION LOT NO. OWNER
S%\ MAIL
4ItACT ADDRESS
NO. OV'IkBLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. 140.
USE OF
BUILDINGS : 'G..�-r..,. DISTRICT NO. GROUP MAP ,:'PRO ESSfD BY
BK PS
CONTRACTOR
ADDRESS / oh r-s - - CONNECTION DATA
STATION DEPTH
CITY T.L.� NO. 3 =_
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STATE �- L C MANHOLE REFERENCE ) _�, _ UPPER
LICENSE NO,.. �`''j�rr'y /- CLASS > � �5 ""�� -s saw -
NO. DE R"-tJGN OF WO K FEE T' � '-' - i fir'`.
TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO "Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER ® $7.00 J'' i0.''
P.C.NO,
SEPTIC TANK.SEEPAGE PIT OR - fJ <•-�--
PITS AND/OR DRAI.NFIELD @ $10.00 CO,NMP.NO. JOB NO, -
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM 4D $3.00
CONNECT ADDITIONAL BLDG.OR -- AFFIDAVIT I WAIVER EAS[Y[NT RECORD.INSTR,NO. DATE
WORK TO HOUSE SEWER 0 $3.00 tom.
OVERFLOW SEEPAGE PIT.DRAINFIELO - ._ U
EXTN.,CESSPOOL.DRYWELL. $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM $3.00
---- --- STATE ENCROACHMENT CD
MANHOLE - $T 00 PERMIT NO. W
----
INDUSTRIAL O..
WASTE APPROVAL
CHARGES s
OWNERS PERMIT sLA j
AUTHORIZATIONTOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRI ED EXISTING DWELLING
TO T. -hi AALIC SE APPROVALS DAYS INSPECTOR'S SIGNATURE
SI EO THIS. DAY OF
NEW HOUSE SEWER
OWNERS AGENT _ 1 --
�„ CONNECT ADDITIONAL
ADDRESS _ - BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION AND/OR DRAINFiELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY --- -
WITLi ALL COUNTYORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 HERES CERTIFY THAT i AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED S REQIED BV LOS ANGLES CSyUNT--Y�IEND S7 E OF SEWAGE DISPOSAL SYSTEM
CALIFCd7N! OR THAT I AM THE 1„EG AL OWN OF, ND I tND�' DySCONNECT PLUG AND
RESfDE IN, YE b SCR! (5 RESI T_fA PR ABANDON HOUSE SEWER
SIGNATURE " ✓
OF PENMTTTEE `` .+ -- BACKFILL SEPT^{IC,-1"AN 5 ❑
SEEP,PITS) y3 CES,b POOLS ❑
VALm 'TiON CK, M.0. CASH
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