HomeMy WebLinkAbout2931A„A642D CE 808A 9177 APPLICATION
I PERMIT
SEWER ® SEWAGE
DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN
DISTRICT NO. GROUP BK MAP PG PROCESSED BY
BUILDING .dme ® JJird�. 1Jro
ADDRES.22549
G�
�` ��,n ^'7 a'
Diamond Bar
CONNECTION DATA
LOCALITY
NEAREST
STATION -,F� �'- DEPTH
CROSS ST.
MANHOLE REFERENCE UPPER
LOWER
OW c
TYPE OF CONNECTION LENGTH FROM
MAIL 17 7` 1 Irvine Blvd.
ADDRESS 1( (J
Y. CURB P.l. M.L. TO P.I.
-
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1�
I TEL. NO. 731-0141
CO. IMP, NO. JOB NO.
CITYyusti
LEGAL
1
TRUNK PERMIT NO. - ROAD PERMIT NO.
DESCRIPTION LOT NO.
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
residence
STATE ENCROACHMENT
BUILDINGS
PERMIT NO.
//^'79 '�+INDUSTRIAL
Con
CONTRALTORyq��y�oaRj de5 tr. & E ®
WASTE APPROVAL
jjq (�
TT�� 1418
P. ®s Box
B418
CHARGES
ADDRESS 1.
1n-0 9 ®. K�
7
CONNECTION CHARGE FEE
CITY TEL. NO. mJ
LSTATE LIC.
ICENSE NO. 262369 CLASS /�
rei
REIMBURSEMENaT�FEE
NO,
DESCRIPTION OF WORK FEE
APPROtlALS
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
CESSPOOL ❑ DRYWELL ❑
OVERFLOW SEEPAGE PIT, DRAINFIELD
a°
EXTN., CESSPOOL, DRYWELL, MANHOLE
ALTER, REPAIR OR ABANDON HOUSE @
ALTER, REPAIR, SEWER OR
SEWER OR DISPOSAL SYSTEM
SEWAGE DISPOSAL
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILLSEPTIC TANKS ❑
SEEP, PIT(S) ❑ CESSPOOLS ❑
OWNER'S Issuance Fee S r e”
AUTHORIZATION,- TOTAL FEE
I HEREBY ACKNOWLEDGE I HAVE
AND STATE THAT THE AB VE ISACO CORRECT ANDDA RIEE TOLICATION COMPLY
WITH ALL COUNTY ORDINANCES AND .STATE LAWS REGULATING
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
HAVE
PLUMBING AND SEWERS.
TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
TOTHE 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 9 _
SIDE IN, THE ABOVE DESCRIBED RESIDENTIAL1PE RTY.
OWNEROR
J `
OWNERS AGENT
SIGNATURE(.
ADDRESS
OF PERMITTEE
VALIDATION
CK. M.O.
i
CASH