HomeMy WebLinkAbout2937A76A642D CE 808A 9177 PERMITAPPLICATION FOR
SEWER ®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
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BUILDING o
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ADDRESS llmar Dr.
1201 So.
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CONNECTION DATA
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Di and Bar
LOCALITY
STATION •^' .f, �� DEPTH
NEAREST
CROSS ST.
UPPER
REFERENCE�r d LOWER
/Y Builders
Citation Builders
OWNER
MAIL
�3� Irvine ���%td.®
TYPE OF C ONN ECTION,-- --_.,� LENGTH FROM
Y. CURB P,L,. ,l' M.L. TO P.L.
ADDRESS 1
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CITY .L u l n TEL. NO. 731 - of 4i
CO. IMP. NO. JOB NO.
LEGAL 2
TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE
I
BLOCK TRACT 31677
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT
HWY. OR ST. WIDENING
USE OF
BUILDINGSresid
STATE ENCROACHMENT
PERMIT NO.
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Rhoades Cons tr. & Equip.
Rhoades
INDUSTRIAL
CONTRACTOR ,C'
WASTE APPROVAL
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P. ® Box J. 1,.
CHARGES
ADDRESS
86®8 8
CONNECTION CHARGE FEE
Ontario TEL. NO.
STATECITY �jp/�
26369
REIMBURSEMENT FEE
LICENSE NO. CLASS
NO.
DESCRIPTION OF WORK FEE
APPROVALS
DATE
INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO
@I}
t
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 ❑
EXTN., 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 r� C
OWNER'SI
AUTHORIZATION TOTAL FEE Cs
HEREBY ACKNOWLEDGE THI HAVE READ THIS
COMPLY
AND STATE THAT THE ABOVE ISACORRECT AND AGREE TOLICATION
WITH 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 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 1 9 _
SIDE IN, THE ABOVE DESCRIBED RESIDENT=PROPERTY.
�k
OWNER OR
OWNERS AGENT
SIGNATURE
E"' r_
ADDRESS
OF PERMITTEE ,�.8. moo#''
VALIDATION
CK. M.O.
CASH