HomeMy Public PortalAbout4866-4864-4868 ENCINITA AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES g
WILLIAM J. FOX, COUNTY ENDINEER BUILDING
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FOR APPLICANT TO FILL IN LOCALITY T, ,
BUILDING / ` ���
ADDRESS (y CROSS ST ZQ�e i, -
LOCALITY DISTRICT NO SERIAL NO PERMIT NO
NEAREST
CROSS ST
RECE VED BY Ready for Inspection DAT ISSUED
OWNERMAIL
ADDRESS SEIONE -MAP—'BK PG
OCCUPANCY �MAP
CITY G J TEL NO
J CONTRACTOR � f ('�,�'v !/� •fir/ /� J
_ CO.IMP NO /
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,p TEL '�/ TRUNK PERMIT NO
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REGISTRATION NO T �� C STATE
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ROAD PERMIT NO _
LEGAL .r Q STATE ENCROACHMENT
DESCRIPTION LOT NO PERMIT NO
BLOCK TRACT6f // INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO OF LONGS ,� CHARGE��
ak 3�®QQ NOW ON LOT ��
USE DI `�7►9%L/fl�G CONNECTION CHARGE F /
BUILDINGS �/L(
NO DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
9 PUBLIC SEWER 10 $ 350 RECEIPT NO IS DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR EXCEPTION R ORDED
-WORK TO HOUSE SEWER 1 00 � NO
ALTER OR REPAIR EXISTING DATE BY
SEWER OR DISPOSAL SYSTEM 1 00
DISCONNECT AND ABANDON SEWER r
AND/OR DISPOSAL SYSTEM 1 00 I CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR r / s
PITS AND/OR DRAINFIELD 2.00 I STATION� DEPTH r
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 I ' �///� MAIIU�-EF_V ENCE �r 1-LOWE-R
rY�TYPE OF-CON
J CTIONP_'L MEL TO P L FROM �
OWNERS PERMIT $ 1 00 --
- AUTHORIZATION I TOTAL FEE I '9�
I EI
HAVE THIS DATE CONTRACTED WITH THE HERN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'SSIGNATURE7 DATE
DWELLING TO T E PUBLIC SEWER
SIGNED THIS DAY OF ___ 14S''� NEW HOUSE SEWER '
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT _ BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESSAND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL O DRYWELL E]
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL TY ORDINANCES AND STATE LAWS ALTER,REPAIR.SEWER OR
REGULATING PLUM D SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CE THAT I AM PROPE LY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSE AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF C LIFORNIA OR THAT I AM ITN LEGAL OWN-
ER OF THE ABOV ESCRIB D RESIDENTIAL ROP
BACKFILL SEPTIC TANKS
SEEP PIT(S)[] CESSPOOLS�
SIGNATURE
OF PERMITTEE
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