HomeMy WebLinkAbout2921A6A642D CE 808A 9/77 APPLICATION FOR PERMIT
SEWER ® SEWAGE
DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN
DISTRICT NO.
GROUP
MAP IG
PROCESSED BY
I lie'
BK
BUILDING
ADDRESS 22556 E® Birdseye Dr.
CONNECTION D ATA
Diamond Bar
LOCALITY
STATION
e�Vl, DEPTH
NEAREST
!Z
CROSS ST.
UPPER
OWNER Citation Builders
MANHOLE REFERENCE
TYPE OF =CTIO J!�-- - LENGTH FROM
M.L. TO P.L.
MAIL M 'L
1 Irvine Blvd..
Y. P
[ADDRE.5S 731
Tustin TEL, NO. 731-0141
CO. IMP. NO. JOB NO.
CITY�USt
C. ITY
LEGAL
96
TRUNK PERMIT No. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE
31677
BLOCK TRACT
NO. OF EHLDGS.
SIZE OF LOT NOW ON LOT
HWY. OR ST. WIDENING
USE OF
residence
STATE ENCROACHMENT
BUILDINGS
PERMIT NO.
INDUSTRIAL
CONTRACTOR Rhoades Constr. &. Equip-
WASTE APPROVAL
ADDRESS Box 1418
CHARGES
Ontario 8518
CONNECTION CHARGE FEE
CITY TEL. NO. 98
STATE LIC.
262369
REIMBURSEMENT FEE
LICENSE NO. CLASS A
NO.
DESCRIPTION OF WORK FEE
APPROVALS
DATE INSPECTOR'S
SIGNATURE
HOUSE SEWER CONNECTING TO
@
PUBLIC SEWER
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
OVERFLOW SEEPAGE PIT, DRAINFIELD
@
CESSPOOL El DRYWELL El
EXTIN . , CESSPOOL. DRYWELL, MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
ALTER, REPAIR, SEWER OR
SEWER OR DISPOSAL SYSTEM
EWAGEDISPOSALSYSTEM
SEWAGE D
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑
SEEP, PIT(S)EI CESSPOOLsEl
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AGREE TO COMPLY
AND STATE THAT THE ABOVE I CORRECT AND
W!TH 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 I AM PROPERLY REGISTERED AND/OR
TOTHE PUBLICSEWER.
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT IAMTHE LEGAL OWNER OF, AND INTEND TO RE-
SIGNED THIS - DAY OF 19
SIDE IN, THE ABOVE DESCRIBED RESIDIENPAL PROPERTY.
OWNEROR
OWNERS AGENT
SIGNATURE
"443"L-1 /(Z() r
ADDRESS
OF PERMITTEA
VALIDATION
CK. M.O.
CASH
II