HomeMy WebLinkAbout2940A%,A642D CE 808A 9/77 APPLICATION1
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN
DISTRICT NO. GROUP MAP P OCESSED BY
BK
BUILDING •
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ADDRESS
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CONNECTION DATA
Diamond Bar
LOCALITY
STATION `'> eir DEPTH
NEAREST
CROSS ST.
UPPER
MANHOLE REFERENCE / G LOWER
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OWNER
TYPE OF CONNEIO CTN LENGTH FROM
17731 Irvine Blvd®
Y. CURB P.L. M.L. TO P.L.
AMAIL
DDRESS
.
P.C.NO.
Tus to 31 - ®+4i
CO. IMP. NO. J08 NO. �
CITY TEL. NO. (
LEGAL
TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT. NO.
#/� Y1�7
32d.
AFFIDAVIT WAIVER EASEMENT RECORD, INSTR, NO, DATE
BLOCK TRACT (7
NO. OF BLDGS. q
SIZE OF LOT NOW ON LOT J
HWY, OR ST. WIDENING
USE OF
BUILDINGS residence
STATE ENCROACHMENT
PERMIT NO.
(iINDUSTRIAL
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CONTRACTOR Rhaodes Constro & J� ui ®
WASTE APPROVAL
q
BOAC 1418
CHARGES
ADDRESS
®Mario 986-851$
CONNECTION CHARGE FEE
CITY TEL. NO.
A
STATE 2 9
REIMBURSEMENT FEE
CIC.
LICENSE NO.
NO.
DESCRIPTION OF WORK FEE
APPROVALS
DATE
INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO @
'
ccl
PUBLIC SEWER
NEW HOUSE SEWER
SEPTIC TANK, SEEPAGE PITOR
@
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 @
WORK TO HOUSE SEWER
CESSPOOL El DRYWELL [IEXTN.,
OVERFLOW SEEPAGE PIT, DRAINFIELD
@
CESSPOOL, DRYWELL. MANHOLE
ALTER. REPAIR OR ABANDON HOUSE @
ALTER, REPAIR, SEWER OR
SEWER OR DISPOSAL SYSTEM
SEWAGE DISPOSAL SYSTEM 5.
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑
SEEP, PITIS) ElCESSPOOLS El
5�
OWNER'S IssuanceI
AUTHORIZATION TC►TAL FEE �� G)
HEREBY ACKNOWLEDGE THAT I HAVE
TOLICATION COMPLY
,d
AND STATE THAT THE ABOVE IS CORRECT ANDDAGREE
W.- ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
PLUMBING AND SEWERS.
TRACTOR TO CONNECT SHE ABOVE DESCRIBED EXISTING DWELLING
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
TOTHE 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 9 _
SIDE IN, THE ABOVE DESCRIBED RESIDEN PROPERTY.
OWNER OR
/L
/
OWNERS AGENT
SIGNATURE
ADDRESS
OF PERMITTE'�
VALIDATION