HomeMy Public PortalAbout5520 ENCINITA AVE_Sewer__ 76A 6421) - CE808 - 9/73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING �vV
ADDRESS L^
LOCALITY f f
NEAREST
FOR APPLICANT TO FILL IN CRObb S '
LEGAL '!
DESCRIPTION LOT NO OWNER M A y
r, MAIL nn
BLOCK TRACT �,,./ ADDRESS /t/i "r'A
NO OF BLDGS —Mn)SIZE OF LOT NOW ON LOT CITYII) J EL NO 8 7
USE OF DISTRICT NO GROUP MAP pR E SED BY
BUILDINGS
BK p3
CONTRACTOR '
ADDRESS CONNtCTIOM DATA ii
CITY TEL NO STATION DEPTH Y
STATE LIC MANHOLE RUPPER
EFERENCE
LICENSE NO GLASS
NO DESCRIPTION OF WORK FEE TYPE OF ON LENGTH FROM
HOUSE SEWER CONNECTING TO ))ll Y CUP L M
RB L TOP L
PUBLIC SEWER $7 00 f + v
SEPTIC TANK SEEPAGE PIT OR PC NO
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO v ��� JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM S300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAlv[p [AS[M[MT RECORD INSTR NO DATE
WORK TO HOUSE SEWER $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL $500 WY OR ST WIDENING V
ALTER REPAIR OR ABANDON HOUSE �.
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT
MANHOLE $7 00 PERMIT NO U
INDUSTRIAL _ W
WASTE APPROVAL _
OWNERS PERMIT $
/ 0 CH RGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CIDN REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER �- DATE INSPECTOR S SIGNATURE
SIGNED THIS
OWNER
OF VI
19�
OWNER OR G ^ NEZH OU SEBEW ER
OWNERS AGENT
_ CONNECT ADDITIONAL
ADDRESS / BUILDING OR WORK '
I HEREBY ACKNOWLEDGE THAT I HAVE READ THI APPL CATIO SEPTIC TANK SEEP PIT(b)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS_REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICE NSEO AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIF CRNIA OR THAT IAM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED RESIDENTIIIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE
OF PEQ MTTTEE BACKFILL SEPTIC TANKS ❑
K�C'�-
SEEP PIT(S) ❑ CESSPOOLS ❑
Jr VALIDATION CK M 0 CASH
1 :3-on, ao.l o .® 1 5.0 0
76A 642D - CE808 - 9/73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING J 'I
ADDRESS
LOCALITY
FOR APPLICANT TO FILL IN NEAREST �]Q
CROSS ST K L
LEGAL �/
DESCRIPTION LOT NO OWNERZWU 'T
MAIL
BLOCK TRACT ADDRESS /U
NO OF BLDGS D�
SIZE OF LOT NOW ON LOT CITY7Mp/C- t1jT4 NO a
USE OF
BUILDINGS DISTRICT NO I G OUP AP / PROC SED BY
CONTRACTOR P �.7iG7C.
ADDRESS 5��1.() Fi/�C //�/� y/ CONNECTION DAT
CITY O TEL NO a �p�S/- STATION 3 DEPTH >l
STATE LIC MANHOLE REFERENCE V< PPE
LICENSE NO GLASS LOWER
NO DESCRIPTION OF WORK FEETYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L
PUBLIC SEWER 0 $7 00 / PC NO
SEPTIC TANK SEEPAGE PIT OR CO IMP NO (
PITS AND/OR DRAINFIELD $1000 0- JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIV[II [AS[M[MT RECORD INSTR NO DATE }
WORK TO HOUSE SEWER $3 DO >
OVERFLOW SEEPAGE PIT DRAINFIELD U
EXTN CESSPOOL DRYWELL 0 $500 HWY OR ST WIDENING
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM (11 S3 00CDSTATE ENCROACHMENT 1--
MANHOLE $7 00 PERMIT NO W
INDUSTRIAL a-
WASTE APPROVAL GO
{�i���
O iMR,S PERMIT $ 0 O CHARGES —
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_ /1
OWNER OR NEW HOUSE SEWER A�
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(8) /
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
L.FPRR.MlTEE,l?
AND SEWERS CESSPOOL ❑ DRYWELL ❑
CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM 0
LIF CR
OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
THE ABOVE DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWERllkV
'TTEE �j„ BACKFILL SEPTIC TANKS ❑
SEEP PIT(S)
POOLS ❑
VALIDATION CK M O CASU?'
9 1 5Er-_0GT 25 1 0 D 1 5.0 0 ��