HomeMy WebLinkAbout2935A76A642D CE 808A 9/77 PERMITAPPLICATION FOR SEWER - SEWAGE DISPOSAL COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION FOR APPLICANT TO FILL IN DISTRICT NO. GROUP MAP PROCESSED BY fll BK rP�G A ��4 c try.yh✓O®g}-�ryyar Dr. F l e AA.6h✓ di .J..Li CONNECTION DATA ond. Bar NEAREST STATION !. "4DEPTH CROSS ST. ' BuildersLOWER Citation '�j .� � �'71 TYPE OF CONNECTION _ LENGTH FROM MAIL q 773 Iry ne B vd� �e dm Y. CURB P. M.L TO P.L. ADDRESS d. / ( .b JOB NO. /� CITYTustin �A.6 tin TEL. NO. 1- 0141 CO. IMP. NO. LEGAL t}, 1 TRUNK PERMIT NO. ROAD PERMIT NO. DESCRIPTION LOT NO. AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE BLOCK TRACT 31677 NO. OF BLDGS. SIZE OF LOT NOW ON LOT HWY, OR ST. WIDENING USE OF BUILDINGS residence STATE ENCROACHMENT PERMIT NO. INDUSTRIAL CONTRACTOR WASTE APPROVAL 77]] q 1'�q P ® Box 1418 CHARGES ADDRESS e d ®8 4'J'i.le 8 Ontario CONNECTION CHARGE FEE CITY ari® TEL. NO. I <7 STATE �y/�y� LIC REIMBURSEMENT FEE LICENSE NO. 262 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, PITIS) AND/OR DRAINFIELD PRIVATE DISPOSAL SYSTEM CONNECT ADDITIONAL BLDG. OR @ WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT, DRAINFIELD eO 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 BAC KIILL SEPTIC TANKS ❑ 'i.. SEEP, PIT(S) ❑ CESSPOOLS ❑ OWNER'S ce Fee s AUTHORIZATIONjjTTAL FEE I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY 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 1 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 OWNS OF, AND INTEND TO RE- SIGNED THIS DAY OF 9 9 _ SIDE IN. THE ABOVE DESCRIBED RESIDENT] PROPERTY. OWNER OR OWNERS AGENT SIGNATURE � �'^-'�✓ " ^' �' ADDRESS OF PERMITTEE VALIDATION CK. M.O. CASH _.. I