HomeMy Public PortalAbout5470 ENCINITA AVE_Sewer__ 76A 642D -CE808 '10-7, APPLICATION F PERMIT '
COUNTY OF LOS ANGELES SEWER-SE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING S J
ADDRESS
LOCALITY `
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL ..��[[
DESCRIPTION LOT NO. 7`J OWNER L
`—� MAIL
BLOCK TRACT ICJ� ADDRESS
NO. OF BLDGS.
971
SIZE OF LOT X' NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP CESS ED BY
BUILDINGS BK P3
CONTRACTOR IOp � 2V
ADDRESS I CONNECTION DATA/�
CITY / TEL. NO. j STATION '_5— DEPTH
STATE CLASS MANHOLE REFERENCE r �UPPERLICENSE NO: 7 J 11NO. .DESCRIPTION OF WOR FEE TYPE OF CO ION LENGTH FROM
HOUSE SEWER CONNECTING TO 'a•'� Y. UR P.L. M.L.TO P.L.
PUBLIC SEWER @ $7.00
SEPTIC'TANK.SEEPAGE PIT OR P.C.NO.
CO.IMP. NO. � .108 NO.
PITS AND/OR DRAINFIELD @ $10.00 �j
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.%�� a
PRIVATE DISPOSAL SYSTEM @ 53.00 L O
CONNECT ADDITIONAL BLDG.OR /1 I17 AFFIDAVIT WRIVER -¢ASEMEKT RECORD. INSTR.NO. DATE V
WORK TO HOUSE SEWER @ $3.00 G! (,/
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL. @ $5.00 O
ALTER,REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT U
W
MANHOLE 0 $7.00 PERMIT NO. H
INDUSTRIAL z
WASTE APPROVAL
OWNERS PERMIT $ 3 00 CHARGES
AUTHORIZATION TOTAL FEE13 0� CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TOCONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE PECTOR'S S NATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER.
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION 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 I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBE RESIDEN L ROPERTY ABANDON HOUSE SEWER
SIGNATURE ❑
OF PERMfTTEE BACKFILL SEPTIC TANKS
SEEP.PIT IS) El—GESSPOOLS
1 0 !u
VALIDATION CK. M.O. t CASH
�I