HomeMy Public PortalAbout5016, 5010 ENCINITA AVE_Sewer__ DEPART'MEN'T OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING [�O/ `
ADDRESS J
FOR APPLICANT TO FILL IN 1 LOCALITY
BUILDING / E NEAREST
ADDRESS
�hrl,/�1 / CROSS
ST L!✓ �C/�Y/
LOCALITY �o r DISTRICT_NO. SERIAL NO. PERMIT NO.
NEAREST m / A --r ��� ,s
1-3
CROSS ST //p IV" /�/
RE EI Ready for Inspection DA E IS ED
OWNER -
MAIL -
ADDRESS /jp� U/SE�Z OCCUPANCY MAP
�� BK PG -
- X99
CITY TEL.NO.
CONTRACTOR � /.�j�fy, �� GAS CO.IMP.NO.
ADDRESS JOB.NO. w
�/I �l, ?�CP1 TRUNK PERMIT NO. r
CITY' TEL.NO.
r • STATE
REGISTRATION NO. ` ��yf COUNTY ROAD PERMIT NO.LEG _
DESCRIPTION LOT NO .,/ / �� ,�` STATE ENCROACHMENT
PERMIT NO -
BLOCK -TRACT �o�� INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT 54 X IOO NOW ON LOTS CHARG
USE OF
BUILDINGS CONNECTION CHARGE FE
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $ 3.50 [7 RECEIPT NO. DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR XCEPTIO RECORDED
WORK TO HOUSE SEWER - 1.00
ALTER OR REPAIR EXISTING I TE 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/ORDRAINFIELD 2.00 STATIONf DEPTH
CESSP00 L—D RY W ELL ///
SPECIAL CONDITIONS ONLY 2.00 /,�S MA PPE FERENCE !A 6QW"
TYPE OFF,LDMECTI0 LENGTH FROM
OWNERS PERMIT `j I 00
I mu M.L.TO P.L.
AUTHORIZATION I TOTAL FEE d
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER ��'
SIGNED THIS. �-.....mZ2_4.?--..._--.....19✓_�lv NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT - sit--- ---V/_ __ ✓_. BUILDING OR WORK
_ - SEPTIC TANK,SEEP.PIT(S)
ADDRESS.... ........ ...------------.. ....------------------------------ ----- ---------- AND/OR DRAINFIELD
ITHEREBY CK LEDGE THAT I HAVE READ THIS APPLI- CESSPOOL I] DRYWELL Ej�
CAION AND STA 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 ABOVE D SCRIBED R ENTIA p PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE , SEEP.PIT(S)[3 CESSPOOLS❑
OF PERMITTEE.--_ _. -- -!!"t- - !!^GCS.---------_---
76AG42D 663 1/53 •
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