HomeMy WebLinkAbout2922A. PERMIT
!bA642o CE 808A 9177 APPLICATION
SEWER - SEWAGE
DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN
DISTRICT NO. GROUP MAP
BK PG PROCESSED BY
BUILDING
ADDRESS
CONNECTION DATA
Diamond
LOCALITY����
.-�..�* DEPTH
NEAREST
CROSS ST.
UPPER..:
((��
OWNER'm itati Builders
MANHOLE REFERENCE"'�k LOWER
—""-
TYPE OF CONNECTION LENGTH FROM
TO P.L.
MAIL q e 'p a
ADDRESS 17731 Irvine Blvd.
Y. CURB P.L.,. M.L.
"�-"'"'
[�I
ura to TEL.-O. 731 — m +4i
Tustin
CO. IMP. NO. JOB NO.
.la
LEGAL
TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO. 95
'I /�
31677
AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE
BLOCK TRACT
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT L
HWY. OR ST. WIDENING
USE OF 7
BUILDINGS residence
STATE ENCROACHMENT
PERMIT NO.
CONTRACTOR Constr.hO des Consr® CJG � U� a
INDUSTRIAL
WASTE APPROVAL
((yy qq�� q JJ����.g
Pe 0 Box 1418
CHARGES
ADDRESS o
Ontario —�b'I
CONNECTION CHARGE FEE
CITY TEL.NO. J(�
STATE LIC.
LICENSE NO, 262369 CLASS A
REIMBURSEMENT FEE
NO.
DESCRIPTION OF WORK FEE
APPROVALS
DATE
INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO
dd
PUBLIC SEWER
'
G
.NEW HOUSE SEWER
SEPTIC TANK, SEEPAGE PIT OR
@
PITS AND/OR DRAINFIELD
CONNECT ADDITIONAL
BUILDING OR WORK
HOUSE SEWER CONNECTING TO @
SEPTIC TANK, SEEP. PIT(S)
AND/OR DRAINFIELD
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG. OR @
WORK TO HOUSE SEWER
CESSPOOL ❑ DRYWELL ❑
OVERFLOW SEEPAGE PIT, DRAINFIELD
@
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. PIT(S) ❑ CESSPOOLS ❑
ISSUC1nC2 F@2 S ,•^"X t+, �A
G'
OWNER'SA`,
_
p LIT�'IORI�ATION TOTAL FEE / �f
B0 R C
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
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
PLUMBING AND SEWERS.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
1 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 RESIDE L PROPERTY.
OWNER OR
¢' J
OWNERS. AGENT
SIGNATURE j (�
ADDRESS
OF PE RM ITTEE �`-'`" `-'t'{'3�"`—
VALIDATION f
CK. M.O.
CASH -