HomeMy WebLinkAbout2941A6A642D CE 808A 9177 PERMITAPPLICATION FOR
SEWER ® SEWAGE
DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY
DIVISION
FOR APPLICBUILDING``�[Ayy NT T® FILL Ir1''((��
DISTRICT NO. GROUP MAP PROCESSED BY
B�K/ PG%
22B
I
ADDRESS J.J �.dPs P. dJn•,r
Diamond Bar
CONNECTION DATA
LOCALITY
NEAREST
STATION #r'Cps �.L-a^"'DEPTH
.A
CROSS ST.
MANHOLE REFERENCE -- ..UPPER..
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OWNER Lion Builders
OfVER
MAIL bpi E"J9 Z�a��e �1�'d®
ADDRESS (( ( Ja
TYPE OF CONNECTION � LENGTH FROM
V. CURB CONNECTION,
- M.L. TO P.L.
P.C. NO.
JOB NO.
(yry �§
CITY Tustin TEL.NO. 731—oi4l
CO. IMP. NO.
LEGAL
TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFFIDAVIT I WAIVER I EASEMENT RECORD. INSTR. NO. DATE
BLOCK TRACT 31677
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT
HWY. OR ST. WIDENING
USE OF
BUILDINGS
STATE ENCROACHMENT
resi((��
PERMIT NO.
(� '{' �p �i,(y
Cons r. & Equip.
CONTRACTORRhoades
WASTE APPROVAL
ADDRESS 1418
P ® ®® Box
CHARGES
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Ontario
CONNECTION CHARGE FEE
CITY TEL,N0.986-8518
STATE 9 LIC. A
REIMBURSEMENT FEE
LICENSE NO. CLASS
NO.
DESCRIPTION OF WORK FEE
APPROVALS
DATE
INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER
BfR-
NEW HOUSE SEWER
SEPTIC TANK, SEEPAGE PIT OR
@
CONNECT ADDITIONAL
BUILDING OR WORK
PITS AND/OR DRAINFIELD
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 @
ALTER, REPAIR, SEWER OR
SEWER OR DISPOSAL SYSTEM
SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND -
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS
SEEP, PIT(S) ❑ CESSPOOLS ❑
Issuance Fee S - �'�
^'
,AWNER'S ��
AUTHORIZATION TOTAL FEE
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS ICATION
AND AGREE TOLCOMPLY
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I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
AND STATE THAT THE ABOVE IS CORRECT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
TO THE PUBLIC SEWER.
LICENSED AS REQUIRED BY LOS ANGELES 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 ABOV ESC RIBED RESIDENTIAL P ERTY.
OWNER OR
t
OWNERS AGENT
SIGNATURE
ADDRESS
OF PERMITTEE
I
VALIDATION \
CK. M.O.
CASH `
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