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Home My WebLink About1086A � , , .,.,_.,..� . . ._ _... ,., �.r .,._ . - 76A642D � GEB08(REV.6/76) �� AF°1�LI�,o�.TiC�N FC)R �'��R11/t1T � � �_ SE�� - s�vv�G� Di��c��,�L COUNTY�F LC)S ANIP�LES BE99lDiPdG AND SAFE?Y FOR APPLICAI�I7 TO FI�L IN DISTRICT NO. GR UP - MAP PROCESSED 0Y /BN PG � AqDRESS 2' r � � e"~ � � �, � ��—�a� �ONPIECTION DATA LOCALITY q NEAREST � SYATION .�""..,,�, / � pEP7N '� CROSS ST. _i.,l�� Ti • h9ANHOLE REFERENCE � �/� UPPER / WER OWNER � �f TYPE OFCONN�CTION �ENGTH FROM MAIL � -� Y. GURB .L. � M.L.TO P.L. ADDRESS � � � �' , � P.C.NO. �/��1 �`� CO.IMP.NO. JOB NO. ��6� CITY ,f, TEL.NO. LEGAL � T62UM6C PERMIT NO. ROAD PERM17 NO. DESCRIPTION LOTNO. ` i e, AFFIDAVIT W4'��VFR EASEMENT RECORD.INSTR.NO. DATE 9LOCK TRACT QFr NO.OF 13LDGS. SIZE OFLOT NOW ON LOT HWY.OR ST.NlIDENING USE OF BUILDINGS STATE ENCROAGHh7EiVT PERMIT NO. INDUSTRIAL CONTRACTOR �- WASTE APPROVAL � i CHARGES ADDRESS � a � CITY TEL.NO. GONNECTION C;.HARGF_FEE � STATE , t.• �• �. LIG. �p �� REIMBURSEMENT FEE � LICENSE NO. � CLASS � NO. DESGRIPTION OF WOF2K FEE APPR�V�LS DATE IN GTOR �SIGNATURE , HOUSE SEWER CONNECTING TO � PUBLIC SEWER . SEPTIGTANK,SEEPAGEPITOR � NEWFidUSESEWER } � � PITS AND/OR DRAINFIELD CONNECT ADDIT�ONAL EA9 hiOUSE SEWERGONNEGTIMG TO BUILDING OR M✓pRK �u PRNA76 DISPOSAL SYSTEM � . SEPTIC TANK.SEEP.PIT�S) �Y � GONNEGT AD�ITIONAL BLDG-OR ANb/OR�RAINPIEL� INORK TO HOUSE SEWER � O%ERFLOW 55EPAGE PIT,DRAINFIELD � EXTN.,CESSPOOL,DRYWELL,MANFIOLE GESSP�OL ❑ DRYWELL❑ ALTER,REPAIR OR ABAN�ON HOUSE � - ALTER,REPAIR.SEWER OR SEWER OR DISPOSAL SYSTEM SEWAGE�ISP�SAL SYSTEM DISCONNEGT PLUCx AND ABANDONhIPUSESEWER BACKFIL.L SEP71C 7ANK5�] � �`•iwA�e9�' Permlt � �^^_��_ /J SEEP.P1T�57❑ CE5$POOLS❑ •�eri R aA AUTFiORIZATION TOTAL FEE �� lALIDATION 7 HAVE AT TH�S DATE A CONTRACT WITH-THE HERSIN NAMED GON- S2 � �YS � �y + . TRACTOR TO COIJNEC7 THE i1BOVE DESCRI6ED EXISTING bV1fElLING r �'�`� 4} '� TOTHH PUBLIC SEyy)E . SIGNEDTHIS / _DAYO,,�� i � ''�'j'<� s w.'� g � .... I OWNEROR r OWNERS AGENT , .x...�.. �} , .,P i9 6U�'� LJ,.{�.��),.... ..., i�. { . ADDRESS . "' -� � >-:x � I HEREBY ACKNOWLEDGE THA7 I HAVE�READ THIu APPLICATION � � tr ( r"�`,9"}L`'i",_, , _ , � AND STATE l'HAT THE ABOV6 IS CORRECT AND AGREE TO COMPIY � PLIUMBING ANO SEW R5,�NANCES AND�STATE LAWS REGULATING �t �y :� (�:�� i. _ u i HEREBY CERTIFY THAT I AM PROPERLY REGI5TEF7ED ANO/OR LICENSED AS REOUIRED BV LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWNER OF,AND INTEND TO RE- SIDE IN,THE A90VE DESCRIBED RESIpENTJQI.PROPERTY.� 9 f, � SIGNATURE � qF PERMITPEE �,. - . . , _... � . ... . «v..�+. . . . . '. .. .. . ,.,� ,:�.,�..,..��. . . . . . . . . - . . ,.,.�.„�.�.�' . � _-_. _ . .___ . _ , ��ET�1'�BSE a�E��a°S��T��3�9 1. iNDICATE a"aL! BUfLC1l�IGS UN PR�PERTY. .p�.�.�.� — .� 2. INQIC�TE At�t� �IlV'�E'°�1Sf�'Jlvi .°a'c1�-1�,�`-�E CiS�'C3Sl�,i. �'�usEP+� �t`,�1�H T!E I��T��°��S T� �UiLi?i��S ,�tND 9�€;£�PF(2i'1`LiR;ES. � � � � , <° �a::. � �.`:� 3.4N�f�,AT� u1�E t�� S��7rC Tlai��i�-�rPiH O� SEEP- ,`�; AGE PlTiS!-S1Z��F�Ea�P�?OL(S1. .. . . _ . . , :-.�w� 4. s�lC31GAT�i��RTF�DfRECi(��C��F!t�T. . - rt . , S. lN�1�I��E�C�T�iSi�'�ETSlF�;��i�ER. <.. � . , . 4 .�: . . � , . ± _ � � �.€� . ST,�L.l.�"t R/�f Y F��Li3;�i�T�� --�___. �.M_ ,�.