HomeMy Public PortalAbout5033 ENCINITA AVE_Sewer__ . i
/CEBOB 3-62 • ,
76AG42D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL tl
DEPARTMENT OF COUNTY,ENGINEER
BUILDING AND SAFETY DIVISION FN
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN. Sup't of Building
J
F R TO FILL 7
LEGA
DESCRIPTION LOT NO OWNERMAIL
(j
BLOC TRACT P-/ S /// "• ADDRESS I '
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS
GROUP DISTRICT N MAP PROCESSED BY
�.Q BK PG
CONTRACTOR ` /� ✓�0
ADDRESS ��i o �/. �i(!'C CONN CTION DATA
CITY TEL NO G�.jyL STATION DEPTH
STATE UPPER
REGISTRATION NO COUNTY MANHOLE EFERENCE LOWER
NO DESCRIPTION OF WORK FEE TYPE OF NNECTION LENGTH FROM }
HOUSE SEWER CONNECTING TO Y RB P L -L TO P L O
PUBLIC SEWER @ $5 00
SEPTIC PC NO
TANK SEEPAGE PIT OR CO IMP NO .10B NO V
PITS AN D/
DRAINFIELD � $10 00 �
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO O
PRIVATE DISPOSAL SYSTEM @ $300 0
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEM[ T RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL,DRYWELL,MANHOLE @ $5 00 h
AI WE 'ABANDON HOUSE HWY OR ST WIDENING
5li�RDISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
- INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s z 00
CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EX15TING DWELLING APPROVALS
TO TL'!E PUBLIC SEWER DATE INSPECTO SIGNATURE
SIGNED THIS DAY-OF
OWNER OR "�-�� - NEW.HOU_SE SEWER
OWNERS AGENT - --+
CONNECT ADDITIONAL -- -- - - _
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S)
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 ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR,SEWER OR '
LICENSED AS REQUIRED BY V. -LE S N AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM L O F, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN,-THE ABOV ES AL OPERTY
ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTE
SEEP PITS) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
CK M O CASH
SUPERVISING MECHANICAL ENGINEER
-
L 1Lo ) J �J UR yI V Q 5-00-
r