HomeMy WebLinkAbout2942A%6A642D CE 808A 9/77 PERMITAPPLICATION FOR
SEWER ® SEWAGE
DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY
DIVISION
ILL IN
APPLICANT T®FILL
DISTRICT NO. GROUP MAP PROCESSED BY
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BUILDING��Fjj®ryR ''I1��
ADDRESS 6.�s B1. �`l.Re�� 1J ®
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Diamond Bar
CONNECTION DATA
LOCALITY
STATION / DEPTH
NEAREST
Pg''71'7
CROSS ST.
MANHOLE REFERENCE / ..?" LOWER
ry
99 Builders
C i Builders
Citation
OWNER
TYPE OF CONNECTION LENGTH FROM
yyyt ppp�999.tion
MAIL ���°� ��'��dl� ���(®
Y. CURB P.L. M.L. TO P.L.
ADDRESS
P.C. NO.
�y 1 �1,
Tustin 31 ®0+ T i
CO. IMP. NO. JOB NO.
CITY TEL. NO.
LEGAL
TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFFIDAVIT WAIVER EASEMENT - RECORD. INSTR. NO. DATE
BLOCK TRACT 31677
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT J.
HWY. OR ST, WIDENING
USE OF BUILDINGS residence
STATE ENCROACHMENT
PERMIT NO.
/� (; Q, �-1'
& Equip.
INDWASTE
CONTRACTOWho'a`-'(es ®
APPROVAL
F. 0 ® Box 1 1
Box
CHARGES
ADDRESS
O [ QQ Q
Ontario 986®C? 18
CONNECTION CHARGE FEE
CITY TEL. NO.
STATE p
262309 d`L
REIMBURSEMENT FEE
L CENSE NO. CLASS
NO,
DESCRIPTION OF WORK FEE
APPROVALS
DATE
INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO @�,y
PUBLIC SEWER
NEW HOUSE SEWER
SEPTIC TANK, SEEPAGE PIT OR
@
PITS AND/OR DRAINFIELD
CONNECT ADDITIONAL
BUILDING OR WORK
HOUSE SEWER CONNECTING TO @
SEPTIC TANK, SEEP, PIT(S)
AND/OR DRAINFIELD
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG. OR @
WORKTO HOUSE SEWER
OVERFLOW SEEPAGE PIT, DRAINFIELD
@
CESSPOOL ❑ DRYWELL ElEXTN.,
CESSPOOL, DRYWELL, MANHOLE
ALTER. REPAIR OR ABANDON HOUSE
CO
ALTER, REPAIR, SEWER OR
SEWER OR DISPOSAL SYSTEM
SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER `
BACKFILL SEPTIC TANKS ❑
SEEP, PITIS) ❑ CESSPOOLS ❑
cpc'A
OWNER'S IssuanceFee sI
(�
AUTHORIZATION 12LAL FEE 1 G� �
HEREBY ACKNOWLEDGE THAT I HAVE
AND STATE THAT THE ABOVE IS CORRECT AND DAGREE TOTHIS COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
HAVE
PLUMBING AND SEWERS.
TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
1 HEREBY CERTIFY THAT t AM PROPERLY REGISTERED AND/OR
TO THE PUBLIC SEWER.
LICENSED AS REQUIRED BY LOS ANG ELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO RE-
SIGNED THIS - DAY OF 19 _
SIDE IN, THE ABOVE DESCRIBED RESIDENTf ROPERTY.
OWNER OR
�_ f
OWNERS AGENT
SIGNATURE €"yrp`
ADDRESS
OF PERMITTEE`�_
VALIDATION
CK, M.O.
CASH _ �`