HomeMy Public PortalAbout5210 ENCINITA AVE_Sewer__ D APPLICATI.ON FOR PERMIT 1
8&EE-681DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of LOs Angeles 17�"`
ILDING �- �J I'��A/�/` - l ,JOHN A LAMBIE, COUNTY ENGINEER DRESS ✓ �(" (J l �l
® -CASSATT D GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO-FILL IN CROSS ST.
LEGAL OWNER
BLOCK
DESCRIPTION LOT NO 4a V/1/1 -
BLOCK TRACT]- ,7 F ADDRESS MAIL
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F- OBLDGS. r�S
L. NO, `�
SIZE OF LOT - NOW ON LOT
USE OF TRICT GROUP MAP
BUILDINGS c-r/
,y/ B PG
CONTRACTOR -
CONNECTION DATA
ADDRESS/ ,
�I
®U • ' � ��� ION �O DEPTHCITY G v TEL. NO. HOLE REFERENCEPPER
REGISTRATION NO. / ��1'ATE
❑ COUNTY _ _ _
No. DESCRIPTION OF WORK FEE TYPE OF CONNECT IO LENGTH-FROM
HOUSE SEWER CONNECTING TO Sl Y. CURB P L M.L.T P.L. - -
PUBLIC SEWER Q $3,50, V
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3 00 _
OVERFLOW SEEPAGE PIT, DRAINFIELD _ P C. NO. '-�4-2-7 7
-
EXTN ,CESSPOOL,DRYWELL,MANHOLE,@ $2 00 'CO IMP. NO. J�8ii6.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1 00 'TRUNK PERMIT NO. ROAD PERMIT NO.
CONN ECTADDITIONAL BLDG OR . STATE ENCROACHMENT '
WORK TO HOUSE SEWER Q $1 00 PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL ,
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL '
CHARGE
Ld CONN 1HARG E
OWNER'S PE T s 1 00 .
1
AUTHORIZATION FEE TOTAL FEE � v
I HAVE AT'THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSCTOR SSINATUE
'
TRACTOR-TO CONNECT THE ABOVE 'DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR ,BUILDING OR WORK _
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S) '
ADDRESS AND/OR DRAINFIELD -
I HEREBY ACKNOWLEDGE THAT I HAVE READ •THIS APPLICATION CESSPOOL❑ DRYWELL❑ '
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 I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ,ABANDON HOUSE SEWER-
DESCRIBED
OR THAT I AM THE LEGAL ER OF THE ABOVE
DESCRIBED RESIDENT�I PER Y , BACKFILL SEPTIC TANKS❑ ,
SIGNATURE !!))////�� SEEP PIT(S) ❑ CESSPOOLS❑ -
OF PERMITTEE, -
JOHN A LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A WOOD, CHIEF PLBG INSPECTOR
11 0 GASH . <