HomeMy Public PortalAbout5213 ENCINITA AVE_Sewer__ D
sa E-689 11.99 APPLICATION FOR PERMIT
NDDISPOSAL
8&E•8 - '
DIVISION OF BUILDING ASAFETY SEWER-SEWAGE. D I S POSA L
Department of County Engineer
County of Los Angeles BUILDING /-
JOHN A LAMBIE, COUNTY ENGINEER ADDRESS'
® CASSATT D GRIFFIN, SUPT OF BUILDING _ LOCALITY -
r
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL �•
OWNER C
DESCRIPTION LOT NO _
MAIL
BLOCK TRACT _ - ADDRESS
NO..OF BLDGS. CITY +C�CJ3 TEL.. 0.
SIZE OF LOT NOW ON LOT
USE OF
BUILDINGSDIST 0. GROUP MAP
BK PG
CONTRACTOR
ADDRESS /Q� /f CONNECTION DATA
CITY ` 'I(IQI Z TEL. NO. �j, STATION DEPTH ,
_ L MANHOLE REFERENCE - UPPER
[ISTATE LOWER
REGISTRATION NO. ❑ COUNTY -
NO. DESCRIPTION OF WORK FEE
_ _ TYPE OF•CONNECTION _LENGTH FROM _
j HOUSE SEWER CONNECTING TO Y. CURBP L. M.L.TO 0.L.
PUBLIC SEWER @ $3 50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $ 3 00 -
OVERFLOW SEEPAGE PIT, DRAINFIELD _ P. C. N0.
EXTN ,CESSPOOL,DRYWELL,MANHOLE Q $ 2 00 CO IMP NO JOB NO.
_ HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO.* ROAD PERMIT NO
CONNECT ADDITIONAL 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 - -
CHARGES
+ CONNECTION CHARGE FEE
OWNERS PERMIT g 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE n
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE IN ECTOR SSI1G<;ATURE
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❑ w -
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
I 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
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESID(NTrnA PR RTY BACKFILL SEPTIC TANKS[:1SIGNATURE _SEEP PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE ' -
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION. ROBERT A WOOD, CHIEF PLBG INSPECTOR
DIRECTOR, MECHANICAL DEPARTMENT, N O CASH
LEO l 4 7 4 FAR 2 5 2 �