HomeMy Public PortalAbout5527 ENCINITA AVE_Sewer__ D
CE808- APPLICATION FOR PERMIT-
eeoe•e ae COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGIIdEEEBBUILDING
BUMDING AND SAFETY DMSION ADDRESS �d / Z G.Lon._t�L ELS
JOHN A. LAMBIE, County Engwoor 4
CASSATT D. GRIFFIN, Supt of Buddmg LOCALITY6_", 7 ,-� R(
FNEAREST
OR APPLICANT TO FILL IN ,
CROSS STLEGAL �1. iC2-r" d4d�
av
t�
—DESCRIPTION 'L NO �a r OWNER �c a pttF
BLOCK TRACT MAIL
ADDRESS "c ..J�i
//�f� ( NO OF BLDGS
SIZE F LOT 8J NOW ON LOT CITY �*_ %TEL NO
USE DI s DISTRICT NO GROUP MAP P ESSED B
BUILDINGS / � /(�
�g�,, .� ��, � � � BK PG
CONTRACTOR (Td J Flc�
ADDRESS " „ ' `=���,� �y�ir^ 'r9 - CONNE O DATA
CIT� CLZ�TEL NO A l- 7_ �J g ! STATION DEPTH
(/ STATE MANHOLE REFERENCE- UPPER
REGISTRATION NO COUNTY
t NO DESCRIPTION OF WORK FEE LOWER
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q $3 00
SEPTIC TANK, SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
ITS AND/OR DRAINFIELD Q $3 00 Y CURB L M L TOP L
OVERFLOW SEEPAGE PIT, DRAINFIELD �'
EXTN CESSPOOL,DRYWELL MANHOLE Q $2 00
y HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER @ $1 00
ALTER
REPAIR
EPAIROR SYSTEM HOUSE $10 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNEWS PERMIT S 2 1 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE 3 1 V0 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS v DvAT�Ec INSPECTOR S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF I9_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL Q
OWNERS AGENT BUILDING OR WORK 7"1N,4i rl
ADDRESS SEPTIC TANK SEEP,PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑
WITH ALL COUNT ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE-DISPOSAL SYSTEM
I 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNT AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTlAI ROBERT BACKFILL
PIT(S)PTIC CESS OLS
❑
SIGNATURE
OF PERMITTE
®� VAMATIOROBERT A WOOD
p6,
X.p, C"g SUPERVISING MECHANICAL ENGINEER
"' 7 5 7 a n r'r 1 Ij 1 0 A