HomeMy WebLinkAbout2934A6A642D CE 808A 9177 APPLICATION PERMIT
SEWER ® SEWAGE
DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
APPLICANT TO FILL IN
DISTRICT NO.
f���
GROUP
P
MAP
BK PG
�
/C
PROCESSED BY
L°GF'"�y.✓' .y.:.
BUILDINGFOR
.,
12 1 So®
ADDRESS dlllmar Dr.
.�
CONNECTION DATA
LOCALITY
STATION -�^ �'> `j DEPTH
NEAREST
CROSS ST.
UPPER
MANHOLE REFERENCE fib � LOWER
OWNER Citation Builders
TYPE OF CONNECTION __ LENGTH FROM
Y. CURB P.L. M.L. TO P.L.
MAIL .
17731 Irvine Blvd.®
ADDRESS
P.C. NO.
CO. IMP. NO. JOB NO.
pp
CITY 1 TEL. NO. ®
TRUNK PERMIT NO. ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. 1
31677
AFFIDAVIT WAIVER EASEMENT - RECORD. INSTR. NO. DATE
BLOCK TRACT
NO. OF BLDGS.
1
SIZE OF LOT NOW ON LOT
HWY. OR ST. WIDENING
STATE ENCROACHMENT
STATE
NO.
USE OF
BUILDINGS residence
INDUSTRIAL
CONTRACTOR
WASTE APPROVAL
CHARGES
j
/y Box
�j W ADDRESS .G 0 e Bo 1418
Ontario 8
CONNECTION CHARGE FEE
CITY TEL. NO. 1. (� 986-85
STATE 262 LIC.
LICENSE NO. CLASS
REIMBURSEMENT FEE
NO.
DESCRIPTION OF WORK FEE
APPROVALS
DATE
INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO @
p
�*
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
@
CESSPOOL ❑ DRYWELL ElEXTN.,
CESSPOOL, DRYWELL, MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
C°
ALTER. REPAIR, SEWER OR
SEWER OR DISPOSAL SYSTEM
SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND >,
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑
SEEP, PIT(S) ❑ CESSPOOLS ❑
OWNER'S Issuance Fee 5 ✓
Al1TH®RIZATI®N TOTAL FEE.C`
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
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 INTENDTO RE-
SIGNED THIS. DAY OF 19 _
SIDE IN, THE ABOVE DESCRIBED RESIDENTI_ L IROPERTY.
OWNER OR
OWNERS AGENT
SIGNATURE
4.
ADDRESS
OF PERMIT F ...
VALIDATION
CK. M.O.
CASH