HomeMy WebLinkAbout2938A,'6A642D CE 808A 9177 APPLICATION1
SEWER ® SEWAGE DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY
DIVISION
FOR APPLICANT TO FILL IN
DISTRICT N. GROUP MAP PROCESSED BY
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ABUILDING ��jj 7p�
DDRESS 2L. Po�,��
Diamond Bar
CONNECTION DATA
LOCALITY
STATION -- DEPTH
NEAREST
_ ,�
CROSS ST.
MANHOLE REFERENCE /J / UPPER
"/
! • LOWER
OWNER
TYPE OF CONNECTION LENGTH FROM
MAIL ��P°i3� Irvine H����
Y. CURB P. L. M.L. TO P.L.
ADDRESS ((•J
P.C. NO.
pp
CITY ustin TEL. NO. o
CO. IMP. NO, JOB NO.
LEGAL PPgg
1
TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO. G
AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE
BLOCK TRACT m.6
I I
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT 1
HWY. OR ST. WIDENING
USE OF reidenCe
STATE ENCROACHMENT
BUILDINGS
PERMIT NO.
Co str. Adui®
INDUSTRIAL
CONTRACTOR1aoade
WASTE APPROVAL
CHARGES
ADDRESS
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86-8
CONNECTION CHARGE FEE
Ontario TEL. NO. ®
STATECITY
pp//yyQ
262369
REIMBURSEMEN`T,FE EC
CLASSIC.
LICENSE NO. ,A,
NO.
DESCRIPTION OF WORK FEE
APPROVALS
DATE
INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO @
ay,
PUBLIC SEWER -
L"
NEW HOUSE SEWER
SEPTIC TANK, SEEPAGE PIT OR @
CONNECT ADDITIONAL
BUILDING OR WORK
PITS AND/OR DRAINFIELD
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
CO
CESSPOOL ❑ 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 '
SAC KFILL SEPTIC TANKS ❑
OLD NEWS Issuance Fee SI
SEEP, PITIS) ❑ CESSPOOLS ❑
1, g "1/C�
AUTHORIZATION TOTAL FEE
HEREBY ACKNOWLEDGE THIS OMPOLY
T I HAVE DAGREE
: G�'°'�
AND STATE THAT THE ABOVE ISACORRECT AND TO
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 1 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 OF, AND INTEND TO RE-
SIGNED THIS DAY OF 9 _
SIDE IN, THE ABOVE DESCRIBED RESIDENTI I ROPERTY.
OWNER OR
OWNERS AGENT
/
SIGNATURE
ADDRESS
I
OF PERMITTEEY'
VALIDATION
CK. M.O.
CASH
