HomeMy Public PortalAbout5535 ENCINITA AVE_Sewer__ ?:AS42D APPLI ATION FO PERMIT 1-i4 -r
ceoe e•e>. COUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER 1
BUILDING AND SAFETY DIVISION BUILDING , C r
ADDRESS ✓ J
JOHN A. LPiMBIE, County Ea ear �+
C TT D GRIFFIN, Supt of Huildiag LOCALITY
NEAREST 01w
FOR APPLICANT TO FILL IN CROSS ST
LEGAL ('
DESCRIPTION LOT N0,— OWNER t �"
BLOCK TRACT - MAIL
'� ADDRESS,_ �
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY / TEL NO
USE OF
BUILDINGS ° DISTRICT NO GROUP MAP PROCESSED BY
BK PG
CONTRACTOR
ADDRESS �� CONNECTION DATA
i
CITY 7 L NO J STATION 3?', Zr DEPTH
FrSTATE MANHOLE REFERENCE .y
REGISTRATION NO .4 COUNTY 4 LOWER
No I DESCRIPTION OF WORK FEE `
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TYPE OF CTION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR Y CURB P L M L TO P L
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TOP C NO.
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO S
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER @ $1 00
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $100 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE ddREIMBURSEMENT FEE
DATE A CONTRACT WITH THE HEREINAMED CON-
TRACTOR TO CHAVE AT THIONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC ER
SIGNED THI DAY OF S 19 NEW HOUSE SEWER Z
OWNER OR // CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL [j DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL 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 1 A HE LEGAL OWNER�'0 THE ABOVE
DESCRIBED RESIDENTIA P TY f BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP PIT(S) C] CESSPOOLS jEf
OF PERMITTE
®r � iLIDATION OBERT A WOOD
� . 0 CASH SUPER (SING MECHANICAL ENGINEER
rt a .4 �, 9 S DEC 6 :i C D Jc.0 0 �