HomeMy WebLinkAbout2933A6A642D CE 808A 9/77 APPLICATION FOR PERMIT
SEWER - SEWAGE
DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
DISTRICT NO. Gg RjO3UP MAP PfOCES5E0 BY
FOR APPLICANT TO FILL IN
BK PG
ry
BUILDING 227 So. 11il D s
ADDRESS
(�
LOCALITY Diamond. Bar
CONNECTION DATA
NEAREST
STATION 1I DEPTH
CROSS ST.
-.
�r
MANHOLEREFERENCE j-
ER
OWNER Citation Builders
TYPE OF CONNECTION LENGTH FROM
AMAIL ''p` '$
DDRESS 17731 Irvine Blvd.
Y. CURB P.L. �# M.L.TO P.L.
P.C. NO.
CO. IMP. NO. JOB NO. c°r
CITY TEL, NO.
LEGAL ,q [
TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO. .L C7
�%�%
31677
AFFIDAVIT WAIVER EASEMENT - RECORD. INSTR. NO. DATE
BLOCK TRACT
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT
HWY. OR ST. WIDENING
USE OF t�1�
BUILD NGSresidence
STATE ENCROACHMENT
PERMIT NO.
_Dho yes
INDUSTRIAL
CONTRALTO lL Con
WASTE APPROVAL
''DD O
P 0 Bqqox
CHARGES
ADDRESS s a .14 U
("9Q Q
Ontario
CONNECTION CHARGE FEE
CITY is TEL.NO. 7v -v85 .L tJ
STATE ��� LIC.
LICENSE NO. CLASS
REIMBURSEMENT FEE
NO.
DESCRIPTION OF WORK FEE
APPROVALS
DATE
INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO @
�,..
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 @
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT, DRAINFIELD
@
CESSPOOL [I 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 ❑
OWNER'S IssuanceFee SI
AUTHORIZATIONT®TPAL FEE d
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 F, AND INTEND TO RE-
SIGNED THIS DAY OF 19 _
SIDE IN, THE ABOVE DESCRIBED RE IDENTJ ROPE RTY.
OWNER OR
� `� f
_
OWNERS AGENT
SIGNATURE
OF PERMITT E .,,t, ' 0 . , -'4,
ADDRESS
-
VALIDATIONf
CK. M.O.
CASH'+:,`
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