HomeMy WebLinkAbout2918A'nP,642D CE 808A 9/77 APPLICATIONI
SEWER ® SEWAGE DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR Pl
APPLICANT TO FILL Iy'�ya
ADDRESS 225N} 4 E. Bird eye .IJd.
NEAREST
CROSS ST.
OWNER Cia-ta-tion Builder
MAIL 17731 131 Irvine Blvd.E ADDRSS
CITYTI is n TEL. NO. 731-0141
LEGAL ()�
DESCRIPTION LOTNO. 7
BLOCK TRACT 31677
NO, OF BLDGS. 'E
SIZE OF LOT NOW ON LOT •6
USE OF
BUILDINGS residence
rCONTRACTORRhoadesConstr.RESSBox 1418
Ontario TEL. N0,986
E C'1 LIC.
NSE NO. CLASS
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 @
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT. DRAINFIELD
EXTN_ CESSPOOL. DRYWELL, MANHOLE @
ALTER, REPAIR OR ABANDON HOUSE @
SEWER OR DISPOSAL SYSTEM
DISTRICT NO. GROUP MAP PROCE55ED-BY
BK rP�G
CONNECTION DATA
STATION if ✓p') � m �� �5""° DEPTH
MANHOLE REFERENCE /` y' UPPER
s` E✓ "32 ✓ �'� LOWER
TYPE OF CONNECT[ O --.: LENGTH FROM
Y. CURB p.L. M.L. TO P.L.
P.C. NO. t �:
CO. IMP. NO. JOB NO. �
TRUNK PERMIT NO. ROAD PERMIT NO.
AFFIDAVIT I WAIVER I EASEMENT I RECORD. INSTR. NO. I DATE
HWY. OR ST. WIDENING
STATE ENCROACHMENT
PERMIT NO.
.INDUSTRIAL
JIL
WASTE APPROVAL
CHARGES
O
Ilm
8 CONNECTION CHARGE FEE '®
d°L A REIMBURSEMENT FEE
�
APPROVALS DATE INSPECTOR'S SIGNATURE
NEW HOUSE SEWER
CONNECT ADDITIONAL
BUILDING OR WORK
SEPTIC TANK, SEEP, PITISI
AND/OR DRAINFIELD
CESSPOOL ❑ DRYWELL ❑ '
ALTER, REPAIR, SEWER OR
SEWAGE DISPOSALSYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑.
I ❑ ❑
OWNER'S Issuance Fee
s
SEEP, PIT SI CESSPOOLS
AUTHORIZATIONTOTAL FEE)
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 ACONTRACT. WITH THE HEREIN NAMED CO N-
PLUMBING AND SEWERS.
TRACTOR TO CONNECT THE ABOVE DESCRIBED
EXISTING DWELLING
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
TO THE PUBLIC SEWER.
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO RE-
SIGNED THIS DAY OF
7.9 _
SIDE IN, THE ABOVE DESCRIBED RESIDENT PROPERTY.
OWNER OR
/ ! t <
OWNERS AGENT
SIGNATURE ,,' .. z r
ADDRESS
OF PERMITTEE
VALIDATION
CK, M.O.
CASH