HomeMy WebLinkAbout2927AJ6A642D CE 808A 9177 PERMITAPPLICATION FOR
SEWAGESEWER - I AL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN
DISTRICT NO.
GROUP
MAP
PROCESSED BY
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PG
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BUILDING
ADDRESS 22531 E. Birdseye Dr.77}}
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LOCALITY Di and Bar
CONNECTION DATA
NEAREST
STATION,' �✓
41 a,.
DEPTH
CROSS ST,
citationBuilders
MANHOLE REFERENCE J
COy
�i UPPER..
,- �„i' LOWER
OWNER (�J
TYPE OF CONNECTION._..
Y. CURB P.L.
LENGTH FROM
M.L. TO P.L.
MAIL
ADDRESS lrvine Blvd.
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CIT,Tustin TEL. NO. ( 31-0141
CO. IMP. NO.
JOBN .
JOB NO.
LEGAL
TRUNK PERMIT NO.
ROAD PERMIT NO.
DESCRIPTION LOT NO. 22
31677
AFFIDAVIT I WAIVER I EASEMENT -
RECORD. INSTR. NO. DATE
BLOCK TRACT
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT
HWY. OR ST. WIDENING
USE OF
BUILDINGS
residonce
STATE ENCROACHMENT
PERMIT NO.
CONTRACTOR • ��:`^^`-��+ �+�.+aami va. m W ad
ADDRESS P.D. 'Box 1 41 8
CITY Ontario TEL. NO. ITY NO. y m
STATE 262369 LICE. —�A^-
LICENSE NO. ii 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 @
WORKTO HOUSE SEWER
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN., CESSPOOL, DRYWELL, MANHOLE @
ALTER, REPAIR OR ABANDON HOUSE @
SEWER OR DISPOSAL SYSTEM
!4!_ � m WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
REIMBURSEMENT FEE
js APPROVALS DATE INSPECTOR'S SIGNATURE
NEW HOUSE SEWER
CONNECT ADDITIONAL
BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
AND/OR DRAINFIELD
CESSPOOL ❑ DRYWELL ❑
ALTER, REPAIR, SEWER OR
SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑
Issuance Fee
s
SEEP, PITIS) LiCESSPOOLS LiOWNER'S
AUTHORIZATION
TOTAL FEE
t
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN
NAMED
CON-
WITH ALL COUNTY ORDINANCES AND STATE LAWS. REGULATING
TRACTOR TO CONNECT THE
ABOVE DESCRIBED
EXISTING DWELLING
PLUMBING AND SEWERS.
TO THE PUBLIC SEWER.
i HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
SIGNED THIS
DAY OF
8
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF. AND INTEND TO RE-
_
SIDE IN, THE ABOVE DESCRIBED RESIDENT � PROPERTY.
OWNER OR
,.- '''"
OWNERS AGENT
SIGNATURE {
ADDRESS
OF PERMITTER
VALIDATION
CK. M.O.
CASH
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