HomeMy Public PortalAbout5609 ENCINITA AVE_Sewer__ 4BAS42D APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles eulLolNc
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS /7l'//J/7C2 �ri�,
® CASSATT O. GRIFFIN, SUPT OF BUILowc Y /
LOCA LITY'2Ee .���9 4 -4
FOR APPLICANT TO FILL IIIN ceoRss sr.
LEGAL IC O'r I� /M - �✓ OWNER
DESCRIPTION LOT N0. .Ss'G /F� �'���
MAIL
BLOCK TRACTA DRESS r1' / G/JiC7i
y Jl♦� . OF SLOGS. ^/ CITY TEL. NO.
SIZE OF LO G/A ; 'T NOW ON LOT /
USE OF DISTRICT N0. GROUP MAP
FIE,
UILDINGS '
I1 K �FIG
�
CONNECTION DATA
1 STATION t/ DEPTH r-} +--
CIT`I��. ,., MANHOLE REFERENCE
Ey/
STATE OWER
REGISTRATION NO. /' ❑ COUNTY ^
NO. DESCRIPTION OF WORK FEE TYPE OFCTION LENGTH FROM yy
HOUSE SEWER CONNECTING TO yC (- p,L. M.L.TO P.L.
PUBLIC SEWER @ $ 3.50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DHAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, GRAINFIELDP. C. N0.
'EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. N0. /�+P✓6lOB NHOUSE 0. /
ER
PRIVATE DISPOSAL SYSTEMG TO @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG,OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER.REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER-OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
- CONNECTION CHARGE FEE
OWNER'S PERMIT 5 t 00
AUTHORIZATION TOTAL FEE �o REIMBURSEMENT Nr FEE
APPROVALS GATE INSCTOF'SSIGNATURE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON=
TRACTOR TO CONNECT THE ABOVE DESCRIBE . EXISTING DWELLING -
'_ TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS OF 1 CONNECT ADDITIONAL
OWNER OR .>� BUILDING OR WORK
OWNERS AGENT _ b�, SEPTIC TANK,SEEP, PIT(S)
ADDRESS L AND/OR DRAINFIELD
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
ANO 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 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 I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIA�k7ROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE _ / _ SEEP. PIT(S) [_1 CESSPOOLS C.
OF PERMITTEE i, -
i9L
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. Y.0. CPS
1,6r,o2 3 9 5SEP 18 4 450 R