HomeMy WebLinkAbout2932A[A642D CE 808A 9/77 APPL( PERMITCATION FOR
® SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL INp
ADDRESS �`1233�p�q ySo e �j++gillaw Dr.
I OCALITY Diamond Ba
31677
TRACT
NO, OF BLDGS.
LOT
rUSE
NOW ON LOT
7GS residence
ADDRESS r 0 0 s Box 1418
CITY Ontario TEL. NO. 98
STATE 262CLASS
LICENSE NO. H3 ��(v—'19 CLASS
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO @
PUBLIC SEWER
SEPTIC TANK, SEEPAGE PIT OR @
PITS AND/OR DRAINFIELD
HOUSE SEWER CONNECTING TO @
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG. OR @
WORK TO HOUSE SEWER _
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN., CESSPOOL, DRYWELL, MANHOLE C°
ALTER, REPAIR OR ABANDON HOUSE @
SEWER OR DISPOSAL SYSTEM
DISTRICT NO. I GROUP MAP ( PROCESSED BY
BK PG
STATION y '5 DEPTH
MANHOLE REFERENCE � % UPPER
LOWER
TYPE OF CONNECT[ Oy(y .--- ; LENGTH FROM
Y. CURB ( P L. y M.L. TO P.L.
�
CO. IMP. NO. - JOB NO. 3„}; j'
TRUNK PERMIT NO. ROAD PERMIT NO. e�
AFFIDAVIT I WAIVERI EASEMENT RECORD. INSTR. NO. DATE
Ell.
O
CHARGES u
Ix
O
P_
u
Lu
APPROVALS DATE INSPECTOR'S SIGNATURE Z
NEW HOUSE SEWER
CONNECT ADDITIONAL
BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(SI
AND/OR DRAINFIELD
CESSPOOL ❑ DRYWELL ❑
ALTER, REPAIR, SEWER OR
SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑
SEEP PITIS) ❑ CESSPOOLS ❑
OWNER'S w� issuance Fee s�a�
AUTHORIZATION TOTAL FEE ej#�p I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
cl AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
HAVE
TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING PLUMBING AND SEWERS.
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
TO THE PUBLIC SEWER. LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
SIGNED THIS DAY OF 9 _ CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO RE-
SIDE IN, THE ABOVE DESCRIBED RES DEN 4 PROPERTY.
OWNER OR tY/t f pp I _
OWNERS AGENT SIGNATURE
ADDRESS OF PERMIT
VALIDATION
CK. M.O. CASH
HWY. OR ST. WIDENING
STATE ENCROACHMENT
PERMIT NO..
INDUSTRIAL
WASTE APPROVAL
CONNECTION CHARGE FEE
REIMBURSEMENT FEE