HomeMy WebLinkAbout2926AI6A642D CE 808A 9177 PERMITAPPLICATION FOR
SEWER ® SEWAGE
DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL INBKPGBUILDINGyy''y�...r/
DISTRICTNO. GROUP MAP BY
7ESSED
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ADDRESS Lv ® AJ�Y �S� Dr.
Diamond Bar
CONNECTION DATA
LOCALITY
NEAREST
STATION "'rt�' DEPTH
C,y
CROSS ST.
MANHOLE REFERENCE d UPPER:..`
i �+'.�. LOWER
OWNER Cit tion BuidlersTYPE
OF CONNECTION ._ LENGTH FROM
MAIL q yg?3 Irvine Blvd ®
ADDRESS r ( d.
Y. CURB P.L. „� M.L. TO P.L.
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O&
N
usts 731-0141
CO. IMP. NO. JOB
.L
CITY TEL. NO.
LEGAL
TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
31677
AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE
BLOCK TRACT
NO. OF BLDG S.
SIZE OF LOT NOW ON LOT
HWY. OR ST. WIDENING
USE OF
BUILDINGS
STATE ENCROACHMENT
PERMIT NO.
pyr�sl,denc
Rhoades Constr. 3
INDUSTRIAL
CONTRACTOR O ' " ®
WASTE APPROVAL
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P. o Box 18
®
CHARGES
ADDRESS .b
CONNECTION CHARGE FEE
CITY Ontario TEL. NO. 986-8518
STATE ffyy36p� LIC.
26G
REIMBURSEMENT FEE
LICENSE NO. CLASS
NO.
DESCRIPTION OF WORK FEE
APPROVALS
DATE
INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO
@/A
PUBLIC SEWER
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
p
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG. OR @
WORKTO HOUSE SEWER
OVERFLOW SEEPAGE PIT, DRAINFIELD
@
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 1
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑ ` '
SEEP, PITISI Q CESSPOOLS ❑ '
OWNER'S Issuance Fee S ,ea erg r
TOTAL FEE
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AUTFi®RIZATION d/
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CO N-
PLUMBING AND SEWERS.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
TO THE PUBLIC SEWER.
LICENSED AS REQUIRED ByLOS ANGELES COUNTY AND STATE OF
CALIFORN IA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO RE-
SIGNED THIS DAY OF 8 _
SIGNED
IN, THE ABOVE DESCRIBED RESIDENTIA ,P OPE RTY.
OWNEROR
OWNERS AGENT
SIGNATURE
OF PERMITTE 'fC"'
ADDRESS
VALIDATION
CK. M.O.
CASH
0
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