HomeMy WebLinkAbout2936A6A642D CE 808A 9177 APPLICATIONPERMIT
SEWER ® DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY
DIVISION
FOR APPLICANT TO FILL IN
DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
16 0 Soo Dr.
ADDRESS diiS.lmd
LOCALITY Diamond Bar
CONNECTION DATA
NEAREST
�
STATION T- d17 DEPTH
CROSS ST.
REFERENCE ' -.. UPPER -.
Carta.&. ion Builders
Citation
MANHOLE /
€cT• ..ffi�r' _?y LOWER
OWNER
TYPE OF CONNECTION �. LENGTH FROM
MAIL q `(�y
ADDRESS Z 1 Irvine Blvd.
Y. CURB P,L.4 M.L. TO P.L.
tin - 141
P.C.NO.
CO. IMP. NO. JOB NO.
CITYTu
TEL. NO. P ✓1
LEGAL
TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO- 13
qq
3.d. '��
AFFIDAVIT WAIVER EASEMENT - RECORD. INSTR. NO. DATE
BLOCK TRACT
NO. OF BLDGS. q
SIZE OF LOT NOW ON LOT d.
HWY. OR ST. WIDENING
USE OF
BUILDINGS residence
STATE ENCROACHMENT
PERMIT NO.
d
INDUSTRIAL
CONTRACTO)Rho
WASTE APPROVAL
TTjj q Q
P ®. Box 1418
CHARGES
ADDRESS o
CITY Ontario a0 TEL. NO. 86-
CONNECTION CHARGE FEE
STATE LIC.
262369
REIMBURSEMENT FEE
LICENSE NO. CLASS
NO.
DESCRIPTION OF WORK FEE
APPROVALS
DATE
INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO @
,�
PUBLIC SEWER
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 @
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT, DRAINFIELD
C°
CESSPOOL ❑ DRYWELL ❑
EXTN., CESSPOOL, DRYWELL, MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
@SEWAGEDISPOSALSYSTEM
ALTER, REP AIR, SEWER OR
SEWER OR DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑ -;
SEEP, PIT(S) ❑ CESSPOOLS ❑
OWNER'S Issuance Fee 5 0
AUTHORIZATION TOTAL FEE ' TI
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
g (o
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
HAVE
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
I HEREBY CERTIFY THAT I 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 ABOVE DESCRIBED RESIDENT PROPERTY.
OWNEROR
OWNERS AGENT
`t
SIGNATURE
ADDRESS
OF PERMITTE L.• `�-`
VALIDATION
CK. M.O.
CASH '-