HomeMy Public PortalAbout5623 ENCINITA AVE_Sewer__ TEMPLE CHTY
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C808a-aeAPPLICATION FOR PERMIT �N7
EOe ' COMITY OF LOS ANGELES1S
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER - -- - - -- -
BUILDING AND SAFETY DIVISION A-UlDILDINc
ARESS
IOIN A. LAMBIE, County E° i..01
CASSATT D. GRIFFIN, Sup of Buildiuq LOCALITY
NEAREST
FOR APPLICANT TO FILL. IN CROSS ST.
'. DESCRIPTION LOT NO. ,� OWNER ,�(( ./AMAI
' UG L/``
BLOCK TRACT �j
may/ Y V,Fj� ADDRESS
SIZE OF LOT y GI NNO.OF BLDGS. Gie CITY ` .. TEL. ND. /./ -/
NOW ON LOT
USE
BUILDDI,NGS C DISTRICT N0.I GROUP I
BK PG MAP PROCESSED BY
CONTRACTOR IT
ADDRESS CONNECTION DATA
CITY TEL.N0. STATION DEPTH
STATE MANHOLE REFTREI E UPPER
REGISTRATION NO. COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE Oil CONNECTION I LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAI NFIELD @ 53.00
OVERFLOW SEEPAGE PIT. DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ 32.00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @SI.UO CO. IMP. NO. JO
f WORK TO ADDITIONAL
ER CDG.OR @ SI 00 TRUNK PERMIT NO. ROAD PERMIT NO.
ALTER.REPAIR
DAIRoR L SYSTEM HOUSE @ $1.00 STATE ENCROACH
PERMIT NO.
INDUSTR
WASTE41PPROVAL
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
1 TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING lo APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNERS°AGENT BUILDING OROWORKAL
ADDRESS SEPTIC TANK,SEEP.PITS)
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 COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWA GE DISPOSAL SYSTEM
I HEREBY CERTIFY T I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUI D Y LOB ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR T T AM THE LE OWNER F THE ABOVE
DESCRIBED RESIDE TI Pfl0 RTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP. PITS ❑ CESSPOOLS
OF PERMITTE
®' VALIDATION ROBERT A. WOOD
CK. U.0. SUPERVISING MECHANICAL ENGINEER
Li.iD469s � 31 1 o D 3 .00 r