HomeMy WebLinkAbout2920A'6A642D CE 808A 9177 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 BK MAP PGPROCESSED BY
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CONNECTION DATA
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LOCALITY Diamond Bar
NEAREST
STATION �as�) �i`--� DEPTH
CROSS ST.
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MANHOLE REFERENCE
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TYPE OF CONNECTION - -.3 LENGTH FROM
MAIL e ,�
Y. CURB P L., ,,r' M.L. TO P.L.
ADDRES731 S
P.G.NO.
JOB NO.
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Tustin � TEL. NO. 3 d. ®V 1 �,8,
CO. IMP. NO.
CITY
LEGAL
TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO. 97
AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE
BLOCK TRACT 31677
NO. OF BLDGS.
1
SIZE OF LOT NOW ON LOT
HWY. OR ST. WIDENING
USE OF
BUILDINGS residence
STATE ENCROACHMENT
PERMIT NO.
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Constr. & Equip.
INDUSTRIAL
CONTRACTORd1hoa des
WASTEAPPROVAL
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Box1418
CHARGES
ADDRESS
86®818
CONNECTION CHARGE FEE
CITY Ontario TEL. NO. tj
STATE'���p/y (]
236 A
REIMBURSEMENT FEE
LICENSE NO. % CLASS
No.
DESCRIPTION OF WORK FEE
APPROVALS
DATE
INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO @
„Y
`I
t
PUBLIC SEWER
0
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 ElEXTN.,
OVERFLOW SEEPAGE PIT, DRAINFIELD
@
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 I.
BACKFILL SEPTIC TANKS ❑
SEEP. PIT(S) ❑ CESSPOOLS ❑
.,
OWNER'S Issuance Fee s
AUTHORIZATION T®TAL FEE Jf
4
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
I 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 INTENDTO RE-
SIGNED THIS DAY OF 9 _
SIDE IN, THE ABOVE DESCRIBED RESIDE N .IAA PROPERTY.
OWNEROR
,•'� f ��.
OWNERSAGENT
SIGNATURE
ADDRESS
OF PERMITTEE
VALIDATION
CK. M.O.
CASH ..