HomeMy WebLinkAbout2923Ai6A642D CE 808A 9/77 APPLICATIONPERMIT
SEWER ®SEWDISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
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APPLICANT TO FILL IN
BuG
ADDRESS (2544 . BZrdseye Dr.
LOCALITY Diamond Bar
NEAREST
CROSS ST.
OWNER Ci%tation Builders
MAIL
ADDRESS 1 1 1 -31 Irvin Blvd.
CITYTustin TEL.Ng31®0141
LEGAL (']� j,
DESCRIPTION LOT NO. J'Y
BLOCK TRACT 31677
NO. OF BLDGS. 1
SIZE OF LOT NOW ON LOT
USE OF
BUILDINGS residence
CONTRACTOR Constr. Rhoades P'' cl u i ii ®
P
ADDRESS P. 0. Box 1418
CITY Ontario TEL. NO. 9`✓Q 6-8518
STATE�� LIC.
LICENSE NO. 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
OWNER'S Issuance Fee S
AUTHORIZATION TOTAL FEE =��(�
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNEDTHIS DAY OF 19_
OWNER OR
OWNERS AGENT
ADDRESS
VALIE
CK. M.O.
DISTRICTNO. I GROUP MAP P rn��eooeu ar
BK
1,12
[TRUNK
ATION J� a DEPTH
UPPER
NHOLE REFERENCE r LOWER
TYPE OF CONNECTIONy�""" II LENGTH FROM
CURB P.L.
-M:L, TO P.L.
P.C. NO.
. IMP. NO. JOB NO.
PERMIT NO. ROAD PERMIT NO.
AFFIDAVIT I WAIVER I EASEMENT I RECORD. INSTR. NO. DATE
HWY. OR ST. WIDENING
STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
REIMBURSEMENT FEE
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 E
BAC KFILL SEPTIC TANKS ❑
SEEP. PIT(S) ❑ CESSPOOLS ❑
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO RE-
SIDE IN. THE ABOVE DESCRIBED RES DENTI „L PROPERTY.
` f i
SIGNATURE /y/yl (% L iry
OF PE RMITTE E/ ' l�� ��'"""'�
TION
CASH