HomeMy Public PortalAbout5017 ENCINITA AVE_Sewer__ 76A 4642D -CE808 -10-71 APPLICATION FC PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING /
ADDRESS
r
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL r` }
BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRI CT NO GROUP BK PS MAP PROCESSED BY
BUILDINGS
CONTRACTO 'C±�-, �I
� (, A�
ADDRESS
� A
CONNECTION DTA ,+ _
C4TY L STATION DEPTH
S TE LIC MANHOLE REFERENCE JT �- UPPER
-664,11,4101-
LICENSE N CLASS
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB PSL M L TOP L10
PUBLIC SEWER @ $7 00
SEPTIC TANK SEEPAGE PIT OR P C NO
PITS AND/OR DRAINFIELD @ SIO 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM $300
CO ECT ADDITIONAL BLDG OR '` AFFIDAVIT WAIVER -EASEMENT RECORD INSTR NO DATE O
O OUSESEWER @ $300 V
O LOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $500 O
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT W
MANHOLE 0 $7 00 PERMIT NO O_
INDUSTRIAL N
WASTE APPROVAL
OWNERS PERMIT S 3 00
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_ -
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL _
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S) I
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING '
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL Cl
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR '
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER F AND IN ND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED RESID T L PROPE gBANDON HOUSE SEWER
SIGNATURE
11
OF pERMfTT BACKFILL SEPTIC TANKS ❑
��
SEEP PITS) ❑ CESSPOOLS ❑
VALIDATION CK M.O. CASH
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL.
Department of County Engineer
County of Los Angeles BUILDING .,,,{{//., ^
ADDRESS , Erel 1 !/,>t- X U
_ WM.J. FOX. COUNTY ENGINEER
CASSATT D.GRIFFIN, SUPT OF BUILDING LOCALITY f -
FOR APPLICANTT TO FILL
� IN �1 CROSS ST.
LEGAL F, 110 o f-t L �y U I J
DESCRIPTION LOT NO. � I OWNER
1 ry �� O AIL
M
BLOCK TRACT��jjn L dT X 5�Ll,A* I��.J`�I ADDRESS '!�_o 1 NO
SIZE OF LOTg9_'X I'IO r NOWOON LOTS CITY're TEL NO 3g -
USE OF �f
BUILDINGS t�A-frte_ DISTRICT NO. GROUP MAP
" �BK PG '
CONTRACTOR
ADDRESS G CONNECTION DATA
CITY TEL. NO. STATION DEPTH
❑ STATE MANHOLE REFERENCE '7 7 O �1 UPPER
REGISTRATION NO. E3 COUNTY
/ / V
NO IDESCRIPTION OF WORK FEE -
HOUSE SEWER CONNECTING TO TYPE CURB P L M L TO P L
CTION LENGTH FROM y�
PUBLIC SEWER Q $ 3 50 Y �y
HOUSE SEWER CONNECTING TO ,
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG. OR ;7,7P C NO
WORK TO HOUSE SEWER 1 00 CO. IMP. NO ' JOB NO
ALTER OR REPAIR EXISTING ql�(,//
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO ROAD PERMIT NO ^VV //
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISP SAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL,
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
'CONNECTION CHARGE FEE
OWNERSPERMIT S 1 00
AUTHORIZATION TOTAL FEE �(� REIMBURSEMENT FEE
1 HAVE-THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPEgTOR'S SIGNATURE
TO THE PUBLIC SEWER
NEW HOUSE SEWER
SIGNED THIS -DAY OF 19- Z 11
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL[:IDRYWELL EI _
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR, SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM'THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER '
DESCRIBED RESIDENTIAL PROPERTY. ,BACKFILL SEPTIC TANKS C
SEEP. PIT(S) CESSPOOLSEr
SIGNATURE _ _ -
OF PERMITTEE
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR
L&0.7t 2 2S Dec. 9 4 4.5.0 p_,