HomeMy Public PortalAbout5349 VILLAGE CIRCLE DR_Sewer__ 76A 642D - CE808 - 9,-73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER--SE jWkGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS F
LOCALITYFOR APPLICANT TO FILL IN CROSSSSTT-
LEGAL { '-
DESCRIPTION LOT NO. OWNER - -
MAIL
BLOCK TRACT • _ i �_,_. ADDRESS
NO. OF LDGS,
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT N0. GROUP MAP PR ESSED SY
BUILDINGS
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CONTRACTOR
ADDRESS _ �y� CONNECTION DATA
SLP` STATION DEPTH
CITY � '^
STATE (-- LIC MANHOLE REFERENCE �` /x-� UPPER
LICENSE NO: CLASS CLASS (OWER
NO. DESCRIPT N OF W RK FEE TYPE FCONNECTION LENG QML�—
HOUSE SEWER CONNECTING TO Y. -bCUR /-,�,P.L. M.L.TO P.L.
PU BLlC SEWER 0 $7.00 �f a
SEPTIC TANK.SEEPAGE PIT OR Y"�rl,,:N>..-�.' P.C.NO.
PITS AND/OR DRAINFIELD $IO.00 CO.IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT.ADDITIONAL BLDG.OR AFFIDAVIT I WAIVES I EASEME xt RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER 53.00 t
OVERFLOW SEEPAGE PIT.DRAINFIELD O
EXTN..CESSPOOL.DRYW ELL. $5._00 U
ALTER.REPAIR OR ABANDON HOUSE '- HWY.OR ST.WIDENING I[=
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT O
MANHOLE $7.00 PERMIT NO. U
LAJ
-- INDUSTRIAL 0-
D.
WASTE APPROVAL C�
OWN
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O{;NEE S PERMIT—_.— $_ G. i CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE "��--' --
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRARICTOR TO CONNECT THE ABOVE DESCED EXISTING DWELLING _ APPROVALS
TO THE. PUBLIC SEWf - DATE—�INSPECTOR'S SIGNATURE
SIGNED THIS fob DAY OF -- —
R OR NEW HOUSE SEWER ,I
OWNERIS AGENT - CONNECT ADDITIONAL
•'� BUILDING OR WORK
ADDRESS �T.I. APPIICAISEPTIC TANK,SEEP,PIT(B)
LEDG H'A7 I HAVE READ AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY _ J --�
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING - -- ,
PL' ANO SEWERS. CESSPOOL ❑ DRYWELL ❑
HEREBY,CERTI FY THAT I AM PROP GIST'ERED AND/OR A LTER,REPAIR,SEWFA OR
SC£NSfD UIRED BY,LOS AN S. COV Y AN `"STATE OF SEWAGE DISPOSAL SYSTEM
C _,R, OR T AT I A THE LE *P'R OFyA 'INTEND TO - DISCONNECT PLUG AND
RESIDE IN, THE I(g E SG R4$ 1 R ,I<RTY. ABANDON HOUSE SEWER
SIGNATURE �+'� --'� -- — BAKFILL SEPTI TANKS,❑
OF PFQMTT
SEECP.
PIT 15) CESSPOOLS ❑
VA ATION CK. M.O. CASH
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