HomeMy Public PortalAbout5469 ENCINITA AVE_Sewer__ & D
8&E-6APPLICATION FOR PERMIT 1
.eeDIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of LOS Angeles BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS sr --_
LEGAL a
OWNER
DESCRIPTION LOT NO
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS CITY TEL NO ' y,
SIZE OF LOT NOW ON LOT
USE OF DISTRICT N ROUP MAP
BUILDINGS I BK PG
CONTRACTOR
ADDRESS P �� CON/NECTION DATA
CITY TEL NO /a� STATION 67 DEPTH
v d MANHOLE REFERENCE
�d s-1(JS` �y TATE
REGISTRATION NO lad �Pl ❑ COUNTY
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ $3 50 Y CURB P L M L TOP L
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD p C NO
CO IMP NO JOB NO
EXTN ,CESSPOOL,DRYWELL,MANHOLE Q $2 00
HOUSE SEWER CONNECTING TO o
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO ROAD PERMIT NO 1e D
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N ED CON- APPROVALS DATE INS ECTOR SSIGNATURE
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
1 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
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REOUIRED BY LOS AN OUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE L GAL 0 P 5P,OF THE ABOVE
DESCRIBED RESIDENTIAL P OP R Y 0 BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE
JOHN A LAMBIE COUNTY ENGINEER VALIDATION ROBERT A WOOD, CHIEF PLBG INSPECTOR
CK N 0 CASH
�JCO 62 1 � � MAY 21 4 4.5 0 ID