HomeMy WebLinkAbout2945A76A 642L. CE808 B-7/76 APPLICATION FOR PERMIT
SEWER —SEWAGE DISPOSAL
FOR APPLICANT TO FILL IN
DISTRICT NO.
GROUP
MAP
BK
PROCESSED By
I
ILDING
ADDRESS 22 81 E. Birdse y e Dr.
CONNECTION DATA
LOCALITY Dimnond Bar
NEAREST
STATION DEPTH
CROSS ST.
UPPER
MANHOLE REFERENCE
LOWER
Citation Builders
OWNER
_d.
TYPE OF CONNECTION LENGTH FROM
MAIL
_f?_7 3-1 — _Ir_v-1 n e B I v
Y. CURB M.L. TO P.L.
k.p
ADDRESS
P.C. NO
CO. IMP. NO. JOB NO.
CITY Tustin TEL. 14731i6oi4i
EGAL
TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO. 5
31677
AFFIDAVIT i , i:! RECORD. INSTR. 1: DATE
BLOCK TRACT
NO. OF BLDGS.
1
SIZE OF LOT NOW ON LOT
HWY. OR ST. WIDENING
USE OF residence
-STATE
BUILDINGS
ENCROACHMENT
PERMIT NO.
C tr
INDUSTRIAL
��ONTRACTORRjjoade S r •
•CjUjp
WASTE APPROVAL
P. 0. Box 1418
CHARGES
ADDRESS
On
CONNECTION CHARGE FEE
CITY ario TEL. NO.986-8-518
STATE LIC A
REIMBURSEMENT FEE
LICENSE NO. CLASS
NO. DESCRIPTION OF WORK FEE
APPROVALS DATE INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @
SEPTIC FANK, SEEPAGE PIT OR
NEW HOUSE SEWER
PITS AND/OR DRAINFIELD @
CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO
BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM @
SEPTIC TANK. SEEP, PIT(S)
CONNECT ADDITIONAL BLDG. OR
AND/DR DRAINFIELD
WORK TO HOUSE SEWER @
OVERFLOW SEEPAGE PIT. DRAINFIELD
CESSPOOL El ORYWELL El
EXTN..CESSPOOL.DRYWELL. MANHOLE @
I R OR ABANDON HOUSE
ALTER. REPAIR
ALTER. REPAIR, SEWER OR
SEWER OR DISPOSAL SYSTEM @
SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON H.UF)SEWER
BACKFILL SEPTIC TANKS El
SEEP, PITS) El CESSPOOLS El
OMINER'S Issuance Fee $ e)'
AUTHORIZATION
'HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
TOTAL FEE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM PLY
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
H AlL COUNTY AND STATE LAWS REGULATING
T RACTOR To CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
EORDINANCES
PLUMBING AND SEWERS.
TO T H E P UBLIC SEWER,
14. I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED uir/0
OF 19
LICENSED AS REOUIRE 0 BY LOS ANGLES COUNTY AND STATE OF
SIGNED THIS -DAY
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO
OWNER OR
RESIDE IN, THE ABOVE DESCRIBED ENTIAL PROPERTY.
OWNERS AGENT
SIGNATURE
ADDRESS
OF PERMrTTEJrtkt
mm7
VALIDATION
CK, M.O.
CASH