HomeMy Public PortalAbout5710 ENCINITA AVE_Sewer__ SG42E-6D 11-45
& APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department County of Lo A eleEngs. ex ADDRESS • _
County of Los Angeles. A. HE nG T
JOHN A. LAMBIE. COUNTY ENGINEER X
® CASSATT D. GRIFFIN. SUPT OF BUILDING LOCALITY
R APPLICANT TO FILL IN GROSS ST
FO .
LEGAL /J� d
DESCRIPTION LOT NO, P W * 7 OWNER
MAIL
BLOCK TRACT / //gODREES '
�) �t N0. OF BLDGS. D.t" "BITY �'� TEL. NO.
512E OF LOT (7 Jw / y (J NOW ON LOT ,QI_[QL,n _
USE
0�� DISTRICT NO. GROUP MAP
E SK
BUILDINGS
w
CONTRACTOR _Z- � �PG
.. ADDRESS 'Z 7 �, / CONNECTION DATA
4 STATION 54 DEPTH
CITY TEL. NO, UPP R
.MANHOLE REFERENCE /
WER
REGISTRATION N0. G 6 ❑ COUNTY 1
No. DESCRIPT ON OF WORK FEE
HOUSE SEWER CONNECTING TO _ I TYPE OFSgMy✓;CTION LENGTH FROM J�
Y. /CURB) P.L. M.L. TO P.L. of
PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $ 3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD CO. IMP. NO. ,3 7� P. C. N0.
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 JOB NO,
HOUSE SEWER CONNECTING TO qJ q ,
PRIVATE DISPOSAL SYSTEM @ $ L00 TRUNK PERMIT N0. ROAD PERMIT N0. -/ Q
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 $ 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE 4y111
APPROVALS DATE INSPECTORS SIGNATURE
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
'TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING f
TO THE PUBLIC SE'WER., NEW HOUSE SEWER -J
SIGNED THIS QDAY OF-' 19_ _ CONNECT ADDITIONAL
OWNER OR BUILDING OR 'WORK
OWNERS AGENT SEPTIC TANK,SEEP. PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING A14D SEWERS. SEWAGE DISPOSAL SYSTEM
1 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 PROPE TY. BACKFILL SEPTIC TANKS❑ e)
' SIGNATURE / ' /I SEEP. PIT(S) [❑ CESSPOOLS 6
OF PERMITTEE ��n���.�'
JOHN A. LAMBIE, COUNTY NGINEER VALIDATIO��OBERT A. WOOD, CHIEF FLOG. INSPECTOR
CK. M. O. CPSH
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