HomeMy WebLinkAbout2946A76A 642L CE808 8-7/76
APPLICATION FOR PERMIT
SEWER —SEWAGE DISPOSAL
FOR APPLICANT TO FILL IN
DISTRICT t40.1
GROUP
MAP
PRPCESSED BY
BUILDING
ADDRESS 22587 E. Birdse e Dr.
LOCALITY Diamond Bar
CONNECTION DATA
NEAREST
STATION DEPTH
CROSS ST.
UPPER
MANHOLE REFERENCE
OWNER citation Builders
LOWER
TYPE OF CONNECTION/
ONN LENGTH FROM
ECTION'��D-
MAIL
17731 Irvine Blvd.
Y. CURB M L. TO P.L.
ADDRESS
Tus -1, 1 n ® 41
73101
P.C. NO,
NO. JOB NO.
CITYTEL. NO.
Co. IMP.
-LEGAL T+
TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO,
31677
AFFIDAVIT WAIVER E111"EINIT REC, DATE
BLOCK TRACT
� �
NO. OF BLD S.
SIZE F LOT NOW ON LOG I
HWY. OR ST. WIDENING
U_ SE OF
BUILDINGS
STATE ENCROACHMENT
__ __r
PERMIT NO.
C'ONTRACTORRhoades Constr. & Equip.
INDUSTRIAL
P. 0. Box-14-1a--
WASTE APPROVAL
ADORE
sbnt-ar
CHARGES
i
CONNECTION CHARGE FEE
CITY I TEL. NO.
!�TATIE
LIC
�?2 3 �g A
REIMBURSEMENT FEE
LICENSE:
LASS
DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
APPROVALS
NO.
DATE
INSPECTOR'S SIGNATURE
PUBLIC SEWER @
SEPTIC FANK. SEEPAGE PIT OR
NEW HOUSE SEWER
PITS AND/OR DRAINFIELD @
HOUSE SEWER CONNECTING TO
CONNECT ADDITIONAL
BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM @
CONNECT ADDITIONAL BLDG. OR
SEPTIC TANK, SEEP, PIT(S)
AND/OR DRAINFIELD
WORK TO HOUSE SEWER @
OVERFLOW SEEPAGE PIT. DRAINFIELD
E XTN..CESSPOOL, DRYW ELL. MANHOLE @
ALTER, REPAIR OR ABANDON HOUSE
CESSPOOL D DRYWELL ❑
ALTER, REPAIR, SEWER OR
SEWER OR DISPOSAL SYSTEM @
SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOU SESEWER
BACKFILL SEPTIC TANKS ❑
SEEP PIT(S) CESSPOOLS
OVY'NER'S lIssuance Fee
AUTHORIZATION TOTAL Ff
'HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAME000N-
WITH ALL COUNT ORDINANCES AND STATE LAWS REGULATING
TRACTOR TOCONNECT THE ABOVE DESCRIBED EXISTING DWELLING
IN
PLUMB AND SEWERS.
TO T H E P UBLEWER,
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
SIGNED THIS DAY OF 19
LICENSED L
OWNER OR
CALI FORN A OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO
RESIDE IN, THE_*BOVE DESCRIB.O&)ENT.AL PROPERTY.
OWNERS AGENT
SIGNATURE
'Y
ADDRESS
OF PERMI`TTE�P 1, 1 I
VALIDATION
CK. M. 0.
CASH