HomeMy Public PortalAbout5641 ENCINITA AVE_Sewer__ :6064 $-55
7085420 APPLICATION FOR PERMI
COUNTY OF LOS ANGELES SEWER-SEWAGE DIS OSAL
DEPARTMENT' OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEAR75T
G 7
.1011\ A. LA\161E, Coumy 1?ngineer sCOLEIMAN IV. JENKINS.Sup'1. of BuildingY 9
FOR APPLICANT TO FILL IN `ROSS ST. l lJl�
LEGALOOL y R'�I-�- I MAIL
DESCRIPTION LOT NO --I'-��-�-� /' . OWNER . ^
BLOCK TRACT l„Iry�i���O ADORE-.I—
NO. OF BLDG
.S12E OF LOT NOW ON LOT CITY EL,NO.
USE OF OISTRICTNO. ROUP MAP PROCESSED BY.
BUILD INGS -
BK PG
1 I�
CONTRACTOR '1L4_& D–P�(.p�,/y� (f✓ A ,p �,L V
ADDRESS �• ` (y /YJA�VI CONNECTION DATA
CIT TEL. NO, O Z STATION DEPTH
LIC 5E' 9 3 Sim CLUPPER
AIC SS �I f.ug-SC A LOWER
NO., CLASS 6 y( L MgNHOLE REFERENCE
NO, DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE.SEWER CONNECTING TO T. CURB P.L. M.L.TO.P.L.
PUBLIC SEWER 0 $ '5.001 -
PTI TANK, St AGE PIT 00 JOB NO.
PITS AND/DR GRAINFIELD C '$10.00 CO.IMP. NO. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO, ROAD PERMIT NO. V
P91VA TE DISPOSAL SYSTEM @ $ 3.00
CONNECT ADDITIONAL BLOC. n AFFIDAVIT we v[R "5101"T RECORD. INSTF.NO. DATE i'
ATO HOUSE SEWER f $ 3.00,�(Z O
RE R ABANb Nl XOUSE If`rJ!
SEWER OR DISPOSAL SYSTEM G $ 3.00
.-6�R.FF --DIEL HWY. OR ST.WIDENING
a
EX TN.,[ESS POO L, MANHOLE C D 5.00 N
STATEENCROACHMENT Z
PERCOLATION TEST I@ $ 5.00 PERMIT NO.
.INDUSTRIAL S'
WASTE APPROVAL
CHARGES
OWNERS PER
5 z o0
AUTHORIZATION TOTAL FEE ^ CONNECTION CHARGE FEE
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMEOF'•ION- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER, DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL . A
BUILDING OR WORN �, q
ADDRESS SEPTIC TANK,'.SEEP.PITIS)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION ANO/OR GRAINFIELD
ANN
STATE THAT THE ABOVE I$ CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
C
PLUMBING AND SEWERS. - CESSPOOL [IORYW ELL ❑
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANOIOR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIF O R NIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, TH OVE p�GRIB RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER SIGNATLftE �\ - ❑
OF PERMIT C BAC KFICL S EPTICTANKS
S E f P,P1T1S) ❑ CESSPOOLS ❑
VALIDATION--\
CK. M.0. CASH l
LACO.1 3 7 0-� APR 19 1 0 D 5.00-
q
76A64 tD.6Y APPLICATION FOR PER
C E80 8 1
COUNTY OF LOS ANGELES E -SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
JOHN A. LAMBIE. County Engineer AoOR
WILLIAM A. JENSEN. Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IIN...q_ / EROSS ST.
.
LEGAL -Z+ />tir•V i✓O.
DESCRIPTION LOT NO. OWNER
MAIL r
BLOCK TRACT AODPE553/ ,
N OF SLOGS. 7
SIZE OF LOT NOW ON LOT C TIE-4. _ A(p fj
USE OF 015TRICT NQ GROU MAP PROCESS DY
BUILDINGS
/1 `'l BK PO
CONTRALTO �( �" / /.—
ADDRESS J l COYYNNECTION DATA I-�"
TY EL. NO. O STATION / 7 -s'—' Y DEPTH 7
'`J— STATE N ( \ UPPER
REGISTRATION NO. O/` COUNTY MANHOLE REFERENCE /
NO. . DESCRIPTION OF WORK FEE TYPE OFC ON LENGTH FR h
N OUSE SEWER CONNECTING TO �O Y. CURB P.L. M.L.TO P.L. " }
PU BLIC SEWER ®. 35.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. d
CO.IMP.NO. JOB NO, O
PITS AN OR DRAINFIELD 310.00 � V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00 v ,J (/ w
CONN
Lr HOUSE SEWER BLOC.OR $3.00 AFFIDAVIT wAlvu u3[II[rvi RECORD. INSTR.NO. DATE O
O
OVERFLOW SEEPAGE PIT,DRAINF I ELO I Vr
E%TN„ O
CESSPOOL.DRYWELL.MAN HOLE SSOR) W
ALTER,REPAIR OR ABANDON MOUSE HWY.OR ST.WIDENING N
SEWER OR DISPOSAL SYSTEM ® 33.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER PERMIT E z Do
AUTHORIZATION, TOTAL FEE /) CONNECTION CHARGE FEE
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECTjI T E ABOVE DES. D E.ISTING OW.LLIN
TO THE PUBLIC S� APPROVALS DATE INSPECTORS SIGNATURE
SIGNED THIS DAY OF I _
OWNER OR NEW HOUSE SEWER {
OWNERS AGEN CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE REAP TH15 APPLIC4TION AND/OR GRAINFIELD
ANG STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
HEREBY ERITIT AM PROPERLY REGISTERED AND/Oq ALTER,REPAIR.SEW ER OR
LICENSED AS REQUIRED Y LOS ANGLES COUNTY A p STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT M THE LEGAL OWNER OF, b.INTEND TO DISCONNECT PLUG AND
RESIDE 11 THE ABO OESCRI D R I ENTIA� P PERTY, ,ABANDON HOUSE SEWER
SIGNgTUFE C
OF PERRACKFCKFILBL SEPTIC TANKS
❑ m�� /♦N
MITTEE EEP.PIT(S) ❑ CESSPOOLS A I +Y
VALIDATIOROBERT WOOD
CK. M.O.
SUPERVISING MECHANICAL ENGINEER
C45H
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2 9 9 9 AUG 2 4 1 0 D 7.0 0”