HomeMy Public PortalAbout5344-5346-5348-5350 VILLAGE CIRCLE DR_Sewer__ Lld
76A 642D - CE808 - 9%73 APPLICATION FOR PERMIT '
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
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ADDRESS
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL4.-
DESCRIPTION LOT NO. OWNER /f?
,�j MAIL
"
TRACT -^ ADDRESS
LK
NO, OF SLOGS.
SIZE F LOT IfOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS - DISTRICT N0, GROUP MAP �.p„{i OCESSED BY
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CONTRACTOR ,..- 1 r•� >Ii `..y " - ) €.+. ''J :rn ;n
ADDRESS 5 '* !<h a - � CA.. CONNECTION DATA.
CITY TEL. NO. STATION J°'` E,. f DEPTH
STATE �^ LIC .l MANHOLE RE/FERENCE
LICENSE NOS CiLASS ✓
NO. 1 DESZRIPTION Off WORK FEE _ TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO < Y....'y CURB P.L. M.L.TO P.L.
PUBLIC SEWER 0 $7.00 P,C.NO. `-
SEPTIC SANK.SEEPAGE PIT OR
PITS AND/ I co-imp. NO. JOB NO.
OR DRAINFIELD ;IO.00 —�3
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wMYCR IAIININT RECORD, INSTR.NO. DATE
WORK TO HOUSE SEWER Q $3.00
AEX
_OVERFLOW SEEPAGE PIT.DRAINFIELD
TN.,CESSPOOL..DRYWELL. $5.00 CZ1
TER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
WER OR DISPOSAL_SYSTEM $3_00 STATE ENCROACHMENT O
MANHOLE $7.00 PERMIT NO. W
--- - INDUSTRIAL r_
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 3 'goL
AUTHORIZATION TOTAL FEE ^ CONNECTION CHARGE FEE
I HAVE AT-THIS-DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC :?7,
... DATE INSPECTOR'S SIGNATURE
SIGNF�D THIS- —DAY OF
..,
OWNER- - EW HOUSE SEWER -
OWNERS AGENT
� CONNECT ADDITIONAL
ADDRESS /� - BUILDING OR WORK
SEPTIC TANK,SEEP,PITS)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY -
WITH Aj-.L-COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMAFNG AND SEWERS. CESSPOOL [3DRYWELL
a//HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
L. ENSEll AS REQUIRED 8Y LOS ANGLES,CDU AND STATE OF SEWAGE DISPOSAL SYSTEM
IA ORTHATI AM THE LEGAL ER O¢! AND I ND TODISCONNECT PLUG AMD
DENTHIC Ep R E AL PRABANDON HOUSE SEWER
SIG E 'Y`
OF PEFMTTTEE £ �✓ - BACKFILL SEPTAF1KS ❑
SEEP.PIT($) 0 CE POOLS ❑
VALIDATION CK. M.O. CASH
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