HomeMy WebLinkAbout2930Ai'6A642D CE 808A 9177 PERMITAPPLICATION FOR
SEWAGESEWER -
I ALm
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY
ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN
DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
.22545 E s B i ds ee Dr.
CONNECTION DATA
LOCALITYDiamond Bar
NEAREST
STATION 9 DEPTH � .�.:� /�`%`�J
t�
GROSS ST.
MANHOLE REFERENCE UPPER
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a
OWNER ld,, 4s����T1 JJ L1 �,l4d P. �r7
��� LOWER
TYPE OF CO NN ECTIO LENGTH FROM
MAIL 17731 Irvine Blvd.
Y. CURB P L. ..,,,,% M.L.TO P.L.
ADDRESS t
P.G. NO.
/�
(yry 1 w 0141
TEL. NO.
CO, IMP. NO. -JOB NO.
CITYy,.�,
LEGAL q
TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO. .L �
AFFIDAVIT WAIVER EASEh1ENT RECORD. INSTR. NO. DATE
BLOCK TRACT 31677
NO. OF BLDGS. 1
SIZE OF LOT NOW ON LOT
HWY. OR ST. WIDENING
USE OF
residence
STATE ENCROACHMENT
BUILDINGS
PERMIT NO.
ppyy,, (/�-} pp
Const& Eui
INDUSTRIAL
CONTRACTORRhoades r. ®
WASTE APPROVAL
P 0• Box 1418
CHARGES
ADDRESS e
CONNECTION CHARGE FEE
CITY Ontario TEL, NO. 986-8518
STATE ryryFF99 LIC.
REIMBURSEMENT FEE
LICENSE NO.(6( CLASS ,A
NO.
DESCRIPTION OF WORK FEE
APPROVALS
DATE
INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO @J,.
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 SLOG. OR @
WORK TO HOUSE SEWER
CESSPOOL ❑ DRYWELL ❑
OVERFLOW SEEPAGE PIT, DRAINFIELD
@
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, PITS) ❑. CESSPOOLS ❑ '4
OWNER'S Issuance Fee S "� e
AUTHORIZATION TOTAL FEE CG
I HEREBY ACKNOWLEDGE THAT I HAVE REATHIS
AND STATE THAT THE ABOVE IS CORRECT ANDDAGREE TO COMPOLY
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 1 AM THE LEGAL OWNER OF, AND INTEND TO RE-
SIGNED THIS DAY OF 9 _
SIDE IN. THE ABOVE DESCRIBED RESIDENT] PROPERTY.
OWNEROR
OWNERS AGENT
SIGNATURE_,..'"\
ADDRESS
OF PERT,
VALIDATION
CK. h1.O.
I
CASH .
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