HomeMy WebLinkAbout2929A76Ab,12D CE 808A 9177 APPLICATION PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY
DIVISION
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DISTRICT NO, GROUP MAP PROCESSED BY
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CONNECTION DATA
LOCALITY
NEAREST
STATIONp. DEPTH
CROSS ST.
UPPER
MANHOLE REFERENCE r"") ,.^
LOWER
TYPE OF CONNECTIO LENGTH FROM
MAIL 17731 Irvine Blvd.Y.
CURB M.L.TO P.L.
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ADDRESS ( (�.J
P.C. NO.
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Tustin TEL, NO. 1-0
CO. IMP. NO. JOB NO.
CITY
LEGAL �3 f1
TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO. 6 4!
AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE
31677
I I
BLOCK TRACT
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT
HWY. OR ST. WIDENING
USE OF
BUILDINGS residence
STATE ENCROACHMENT
NO.
RRh ((''�� (� '};PERMIT
INDUSTRIAL
GONTRAGPOR•®�`n'�RR "'� "®Equip.
WASTE APPROVAL
° Box 1418
CHARGES
ADDRESS
86-8o
CONNECTION CHARGE FEE
CITY @J ntari® TEL. NO. (}
STATE Lic. p
2369 A,
REIMBURSEMENT FEE
LICENSENO. CLASS
No.
DESCRIPTION OF WORK FEE
APPROVALS
DATE
INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO
�O
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, PITISI
AND/OR DRAINFIELD
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG. OR @
WORK TO HOUSE SEWER
CESSPOOL ❑ DRYWELL ❑
OVERFLOW SEEPAGE PIT, DRAINFIELD
C°
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, PITISI ❑ CESSPOOLS ❑
OWNER'S Issuance Fee S
AUTHORIZATION TOTAL FEE _ '
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WfTH 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
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 1 AM THE LEGAL OWNER OF, AND INTEND TO IRE -
SIGNED THIS - DAY OF 19 _
SIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PR03 ERTY.
OWNER OR
OWNERS AGENT
SIGNATURE
J T'"�
OF PERM ITTEH �✓` "!"'"
VALIDATION
CK. M.O.
CASH