HomeMy WebLinkAbout2943AADDRESS � rl'�_ KI r(i�ve
LOCALITY Diamond Bar
NEAREST
CROSS ST.Citation
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OWNER Ci t atio byy�reBuilders
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MAIL d. Y 1AEei V (�
ADDRESS
CITY Tustin TEL. NO. 731
EGAL
DESCRIPTION LOT NO.
BLOCK TRACT 31677
NO. OF BLDG5.
SIZE OF LOT NOW ON LOT
USE OF qa�
BUILDINGS residence
CONTRACIOR Rhoades Constr. U+
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CITY TEL. NO.
STATE 2 2369
LIC
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LICENSE NO.
CLASS
lA
NO.
DESCRIPTION OF WORK
FEE
HOUSE SEWER CONNECTING TO
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L,
CONNECTION DATA
STATION r g DEPTH
MANHOLE REFERENCE C...._ O
�` LOWER
TYPE OF CONNECTION LENGTH FROM
Y. CURB P.L.)M.L. TOP.L.
- P.C. NO. �ry�
CO. IMP. NO. JOB NO.
TRUNK PERMIT NO. ROAD PERMIT NO.
AFFIDAVIT WnIVER EASEa EHT RECORD. INSTR. NO. DATE
HWY, OR ST, WIDENING
STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
REIMBURSEMENT
�FEE
y
APPROVALS. Alas DATE INSPECTOR'S SIGNATURE
PUBLIC SEWER �
NEW HOUSE SEWER
SEPTIC TANK. SEEPAGE PIT OR
CONNECT ADDITIONAL
BUILDING OR WORK
PITS AND/OR DRAINFIELD @
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @
SEPTIC TANK. SEEP, PITIS)
-AND/OR DRAINFIELD
CONNECT ADDITIONAL BLDG. OR
WORK TO HOUSE SEWER @
CESSPOOL ❑ DRYWELL ❑
OVERFLOW SEEPAGE PIT. DRAINFIELD
EXTN.,CES5POOL,DR Y WELL. MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
ALTER. REPAIR. SEWER OR
SEWER OR DISPOSAL SYSTEM @
SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
v:
BACKFILL SEPTIC TANKS ❑
v
SEEP, PIT (S) ❑ CESSPOOLS ❑
OWNERaS Issuance Fee $
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AUTHOyTam�+ rp+
RIZ
RIZATION
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.t 'HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
Il S lV TOTAL FEE
G/
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING
PLUMBING AND SEWERS.
TO THE PUBLIC SEWER.
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
)9_
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF
SIGNED THIS DAY OF
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO
OWNER OR
RESIDE IN, THE ABOVE DESCRIBED RESID AL PROPERTY.
OWNERS AGENT
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SIGNATURE ---
ADDRESS
OF PEJ tf-
RM'
VALIDATION
CK. M.G.
CASH ti..