HomeMy WebLinkAbout2938A/hA642D CE 808A 9177 APPLICATION FOR PERMIT
SEWER - SEWAGE
DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IIVyy'
DISTRICT NO GROUP MAP PROCESSED BY
PG
BUILDING L�®
ADDRESS
/{�+B6K✓s
Diamond Bar
CONNECTION DATA
LOCALITY
NEAREST
STATION. DEPTH
CROSS ST.
-
UPPER
MANHOLE REFERENCE
LOWER
OWNER Citation Builders
TYPE OF CONNECTION LENGTH FROM
q ya 'y
ADDLE 31 Irvine Blvd®
Y. CURB P.L.w M.L.TOP".L.
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ustin 731 — W 1 1
CO. IMP. NO. JOB NO. 6 -✓ F,�.
CITY TEL. NO.
LEGAL
TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO. 1 1
.4e
31 6 77
AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO, DATE
BLOCK TRACT
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT
HWY. OR ST. WIDENING
USE OF
BUILDINGS residency
STATE ENCROACHMENT
PERMIT NO.
Rhoades Cons tr. p_ Equip.
INDUSTRIAL
CONTRACTOR SS11 W E1L
WASTE APPROVAL
(y 'q p @
P 0 Box 14�18
CHARGES
ADDRESS e ®
OntarioTEL. g 51
CONNECTION CHARGE FEE
CITY
STATE LIC.
CLASS A
LICENSE NO. 262369 a�.
REIMBURSEMENT FEE
NO.
DESCRIPTION OF WORK FEE
APPROVALS
DATE
INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO
@�*`
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 @
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT, DRAINFIELD
@
CESSPOOL ❑ DRYWELL ❑
EXTN., CESSPOOL, DRYWELL, MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
@
ALTER, REPAIR, SEWER OR
SEWER OR DISPOSAL SYSTEM
SEWAGEDISPOSALSYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑
SEEP, PIT(S) ❑ CESSPOOLS❑
OWNER'5 Issuance Fee s
A I ITHORI�pTI®Ai TOTAL FEE f• ` J
N
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
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AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
I HAVE AT THIS DATE CONTRACT WITH THE HEREIN NAMED CON-
PLUMBING AND SEWERS.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
1 HEREBY CERTIFY THAT f 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 ABOVj DESCRIBED RESIDE IAL PROPERTY.
OWNEROR
I
OWNERS AGENT
SIGNATURE
ADDRESS
OF PERMITTEET �`� `
VALIDATION
CK. M.O.
I
CASH -.