HomeMy Public PortalAbout5331 ENCINITA AVE_Sewer__ S&E-6 911-55 - APPLICATION F'OR -PEF�11l1_IT
DIVISION OF BUILDING AND SAFETY SEWER—S E WAGE, DISPOSAL ,.
Department of County Engineer
t County,of Los Angeles BUILDING J I JOHN A. LAMBIE. COUNTY ENGINEERADDRESS, , 3,3 . g/LCASSATT D GRIFFIN, SUPT OF BUILDING LOCALITY FOR A P NT TO FILL IN CROSS ST.LEGAL -Q / 2 ),/ OWNER fDESCRIPT ^ LOT N0, J! JBLOCK, - TRAC 7 �p '� _ADDRESS.MAIL 3_3NO.OF BLDGSl/y� CITY o� , TEL. NO. � �
"SIZE OF LOT NOW ON LOT C<�! '
USE OF, - DISTRICT NO. GROUP MAP
BUILDINGS B
CONTRACTOR
CONNECTION}-DATA--
ADDRESS -
STATION DEPTH
CITY TEL. NO.- . UPPER-
El
REFERENCE _ _^ � ,
❑ STATE LOWER
,REGISTRATION NO. - ❑ COUNTY
NO. '.DESCRIPTION OF WORK, FEE - -
HOUSE SEWER CONNECTING TO _ TYPE OF CONNECT N -LENGTH FROM
'PUBLIC SEWER @ $3 50 - ,
Y. CURB P.L M.L TO P.L
SEPTIC TANK,SEEPAGE PIT OR 0,/ < �� (I .'a,
PITS AND/OR DRAINFIELD Q $3 00 V - `1. ISI
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C.-NO. '
EXTN ,CESSPOOL,DRYWELL,MANHOLE Q $2 00 _ CO, IMP N0, JOB NO.
HOUSE SEWER CONNECTING TO ,
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK-PERMIT NO.. ROAD PERMIT NO. -
CONNECTADDITIONALBLDG OR - STATE ENCROA M
WORK TO HOUSE SEWER - Q $1 00, PERMIT NO ,
ALTER,REPAIR OR ABANDON HOUSE INDUSTRI L -2
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE AP A - - C3 ,
CHARGES
e
CONNECTION-CHARGE FEE - -
OWNER'S PERMIT $ 1 00
-REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE `
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-• APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIED EXISTING DWELLING TO THEPUBLICSEWER - NEW HOUSE SEWER—
SIGNED THIS DAY OF 19�� CONNECT ADDITIONAL'
OWNER OR BUILDING OR WORK
OWNERS,AGENT , SEPTIC TANK,SEEP, PITS)
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,REP,A IR,SEWER OR '
PLUMBING AND SEWERS SEWAGE DIS POS AL 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 RESIDENTIAL PR ERTY, BACKFILL SEPTIC TANKS❑ ` `' S
`SIGNATURE SEEP PIT(S) Ll CESSPOOLS❑ - _ — — ,
OF PERMITTEE
JOHN A LAMBIE, COUNTY ENGINEER VALIDATIO ROBERT A WOOD, CHIEF PLBG INSPECTOR
CK CASH
LACo 5 0'' 4 � sEP 2 3 10. A 2.00 �"