HomeMy WebLinkAbout2919A6A642D 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
MAP
BY
BK PG
TPROCESSED
7�
BUILDING
BUILDING
ADDRESS
RE 22"
ADDRESS 22566 Birdseye Dr.
LOCALITY Diamond Bar
CONNECTION DATA
NEAREST
STATION DEPTH
CROSS ST.
UPPER
MANHOLE REFERENCE
Builders
& LOWER
O.NEFCitation
TYPE OF CON LrNGTH FROM
MAIL
ADDRESS 17731 Irvine Blvd.
Y. P.L. M.L. TO P.L.
I
P.C. NO.
CO. IMP. NO. JOB NO.
CITY Tustin TEL. NO. 731-0141
LEGAL
TRUNK PERMIT NO. ROAD PERMIT NO.
ESCRIPTION LOTNO.98
DESCRIPTION
AFFIDAVIT I WAIVER EASEMENT RECORD. INSTR. NO. DATE
BLOCK
LOCK TRACT 31677
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT 1
HWY. OR ST. WIDENING
USE OF
BUILDINGS residence
STATE ENCROACHMENT
PERMIT NO.
CONTRACTOrRhoades Constr. & Equip,
INDUSTRIAL
WASTE APPROVAL
ADDRESS Box 1418
CHARGES
Ontario
CONNECTION CHARGE FEE
CITY TEL.NO. 986-8518
STATE LIC.
REIMBURSEMENT FEE
LICENSE N.?_62369 CLASS A
NO.
DESCRIPTION OF WORK FEE
APPROVALS
DATE
INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO @
PUBLIC SEWER
NEW HOUSE SEWER
IT OR
SEPTIC TANK, SEEPAGE p @
CONNECT ADDITIONAL
BUILDING OR WORK
PITS AND/OR DRAINFIELD
HOUSE SEWER CONNECTING TO @
SEPTIC TANK, SEEP, PIT(S)
AND/OR DRAINFIELD
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG. OR
WORKTO HOUSE SEWER @
OVERFLOW SEEPAGE PIT, DRAINFIELD
@
CESSPOOL DRYWELL
0 El
EXTN . , CESSPOOL, DRYWELL, MANHOLE
ALTER, REPAIR OR ABANDON HOUSE @
ALTER, REPAIR. SEWER OR
SEWER OR D SPOSAL SYSTEM
SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS
SElr = P. PIT(S) El CESSPOOLS 0
OWNER'S Issuance Fee S
del-)
AUTHORIZATION TOTAL FEE
I HEREBY ACKNOWLEDGE I HAVE THIS APPLICATION
THAT
AND STATE THAT THE ABOVE IS CORRECT ANDREAD AGREE TO COMPLY
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
WrrH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
T RACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
FLU M BI NG AND SEWERS.
CERTIFY THAT AM PROPERLY REGISTERED AND/OR
I
TO THE PUBLIC SEWER.
N1,,REBY LI
LICENSED AS REQUIRED By OS ANGELES COUNTY AND STATE OF
CALIFORN IA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO RE-
SIGNED THIS - DAY OF 19
SIDE IN. THE ABOVE DESCRIBED ROPERTY.
OWNER OR
OWNERS AGENT
" R�ES,I,DENT
SIGNATURE - �A 9A
ADDRESS
OF PERMIT:E
VALIDATION
CK. M.O.
CASH