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
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CONNECTION DATA
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TYPE OF CONNECTION _ LENGTH FROM
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ADDRESS d. / ( .b
JOB NO.
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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
�
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ADDRESS
OF PERMITTEE
VALIDATION
CK. M.O.
CASH _..
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