HomeMy WebLinkAbout2917ACE 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 PG MAP PROCESSED BY
B ILDING
ADDRESS
U JAi I Ti Us Dr.
'i, ";?
J
Diamond Bar
CONNECTION DATA
LOCALITY
NEAREST
STATION DEPTH
CROSS ST.UPPE
MANHOLE REFERENCE WER
CS�-
OWNER citation Builders
, .
MAIL
ADDRESS 17711 Tryine Blvd.
::�� LENGTH FROM
TYPE OF CONNECTIO��
Y� CURB M.L. TO P.L.
P.G.NO.
CO. IMP. NO. , NO.
CITY, Tustin TEL. NO. 731-oi4i
LEGAL
LOT NO. 100
TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION
31677
AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO, DATE
RLC)-K TRACT
NO. OF BLDGS.
SIZE. F LOT NOW ON LOT
HWY. OR ST. WIDENING
USEODINGS F
BUILDINGS residence
STATE ENCROACHMENT
PERMIT NO.
R6oades Constr. & Equip.
INDUSTRIAL
'WASTE
CONTRACTOR
APPROVAL
ADDRESS P ® 0 . Box 1418
CHARGES
CITYOntario TEL. NO.986-8518
CONNECTION CHARGE FEE
STATE
LICENSE NO. 262369 L,-,c-- A
REIMBURSEMENT FEE
NO.
DESCRIPTION OF WORK FEE
APPROVALS
DATE
INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO
0
PUBLIC SEWER
NEW HOUSE SEWER
SEPTIC TANK. SEEPAGE PIT OR
V..i�N
PITS AND/OR DRAINFIELD
EC`T``'ADDITIONAL
BUILDING OR WORK
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 [j DRYWELL El
EXTN., CESSPOOL, DRYWELL, MANHOLE
ALTER, REPAIR OR ABANDON HOUSE @
ALTER, REPAIR. SEWER OR P
SEWER ORDISPOSAL SYSTEM
SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BAC KFILL SEPTIC TANKS ❑
OWOWNER'S_T Issuance Fee s 129 6'
SEEP, PIT(S) El CESSPOOLS El
AUTHORIZATION I TOTAL FEE
I HEREB ACKNOWLEDGE THAT I HAVE THIS
AN. STATETHATTHE ABOVE IS CORRECT ANDREAD AGREE TOAPPLICATION 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 I 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 19
SIDE IN, THE ABOVE DESCRIBED RESIDENTIAL P ERTY.
-
OWNER OR
OWNERS AGENT -
SIGNATURE
ADDRESS
OFPERMI E
VALIDATION
CK. M.O.
CASH
G