HomeMy Public PortalAbout4845 ENCINITA AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOB ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING ;f�� '`wG,�q�t��
ADDRESS /j �C X1/3
FOR APPLICANT .O FILL IN LOCALITY Yp_0041 06� G lTy'
BUILDINGNEAREST
ADDRESS ^ _ CROSS ST S�/P� B .19/?y�
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LOCALITY DISTRICTNO A SERIAL NO PER/MIT NO r
NEAREST ✓ ~ U J
CROSS ST 10JS RECEIVED BY Reedy for Inspection e DATE ISSUED
OWNER Y llp d �s
MAIL / USE ZONE OCCUPANCY I MAP
ADDRESS �S BK PG
CITY TEL.NO. '` L ���/ C- s
CONTRACTOR Q
` CO.IMP.NO /? 7,;7
ADDRESS / JOB.NO.
CITY TEL NO. TRUNK PERMIT NO.
STATE
8 COUNTY 15�,
REGISTRATION NO ROAD PERMIT NO 7
LEGAL a STA E ENCROACHMENT
DESCRIPTION LOT NO /l p y� ,p PER NO
BLOCK TRACTS�G //f J�S p[/�W INDUST L
WASTE AP OVAL
SIZE OF LOT NO.OF BLDGS CHARGES
NOW ON LOT
USE OFw �/� CONNECTION CHAR FEE
-BUILDINGS
sNO DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ f $50 3 Jv RECEIPT NO X N,'ZTEI
BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG.OR EXCEPTION RE RDED
WORK TO HOUSE SEWER 1 00 NO
ALTER OR REPAIR EXISTING DATE I BY
SEWER OR DISPOSAL SYSTEM 1 00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATIONDEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 / MANHOLE REFERENCE
uftl R LOWER
TYPE OFCONNECTION LENGTH FROM
C
OWNERS PERMIT ¢ I 1 00 �-
AUTHORIZATION TOTAL FEE -0
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING; APPROVALS INSPEC OR'SSIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS____ ___DAY OF.._____ _— __ 19__._ NEW HOUSE SEWER C
CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT _ _ _ _.._ _ ___.._..__ .___. _ _._._r
SEPTIC TANK,SEEP.PIT(S)
ADDRESS _.. _ ._ _....._ _ _ .._ _._ ___ AND/OR DRAINFIELD
CA1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL I] DRYWELL 0
TION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER, REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOV ESCRIBED RESIDENT AL PROPE TY. BACKFILL SEPTIC TANKS
SIGNATURE�JC SEEP PIT(S)� CESSPOOLS
OF PERMITTEE �X _ /
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