HomeMy Public PortalAbout4923 ENCINITA AVE_Sewer__ cEeoe.8•as - APPLICATION FOR PERMIT _
eaos•sCOUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING
ADDRESS ' Encinita & 9,5 . 8�
JOHN A. I AMBIE County Fhigmeer P
ulty
CASSATT D GRIFFIN. Sup't of Budchng LOCALITYNEARM
�' LOm'�'1 Temple
CROSS ST _ Azusa
FOR APPL�I-CANT TOFILL IN �T-
LEGAL
DESCRIPTION LOT NO 97 01 of NJ 100� of 20 OWNER N rman &: Geneva_ Kara:
BLOCK TRACT S*` ADDRESS MAIL o Ind-)id City Clinic
SIZE OF LOT / 1 N LOTS CITY India TEL NO
USE OF
BUILDINGS fDNGROUP MAP PROCESSED BY
BK PG
CONTRACTOR Lt* Lumb, le •r (�-- 6S- a-lc cc �
ADDRESS 67Z San Bernardino, Rd®. CONNECTION DATA
clTY El Monte TEL NO GI 87L55 - j DEPTH
STATEFER CE UPPERREGISTRATION NO > l COUNTY R
No DESCRIPTION OF WORK FEEHOUSE SEWER CONNECTING TO
PUBLIC SEWER S3 00 0 eSEPTIC TANK SEEPAGE PIT OR CONNEC LENGTH FROM /ITS AND/OR DRAINFIELD @ $3 00 CURB P L M L TO P L ��
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN ,CESSPOOL DRYWELL MANHOLE @ $2 00
HOUSE SEWER CONNECTING TO / 7P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 qq CO IMP NO JOB NO
WORK TOCONNCTHOUSEADDITIONAL
SEWEBLDG OR @ $1 00 ` �? TRUNK PERMIT NO ROAD PERMIT NO
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACH NT
SEWER OR DISPOSAL SYSTEM @ $1 00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT 2 100 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE y
I HAVE AT THIS DATEA CONTRACT WITH THE HEREIN NAMED CON_ APPROVALS DATE INSPECTOR S SIGNATURE
TRACTOR TO CONNECT E ABOVE DESCRIBED EXISTI DWELLING Ir
TO THE PUBLICS W R
SIGNED THIS Y OF Igo NEW HOUSE SEWER �y L
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK SEEP,PITS)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLIC ION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY S ANGELES COUNTY AND STATE OF ABANDON HOUSESEWER
CALIFORNIA OR THAT 1 AM THE E AL OWNER Ok THE ABOVE PIC S❑
DESCRIBED RESIDE IA PR ER BACKFILL SEEP PITS SET❑ CESSTANKPOOLS
SIGNATURE
OF PERMITTE "
Cr ATIO ROBERT A WOOD
Ca m o CASH SUPERVISING MECHANICAL ENGINEER
7r113_" Au 'l 3 A
TD
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