HomeMy Public PortalAbout5711 ENCINITA AVE_Sewer__ 24650,INSERTS-/ ,tea o
76A642D APPLICATION FOR PPERIN117.1" / 1
6A6g20 COUNTY OF LOS ANGELES .L
SEWER—SEWAGE DISPOSA
DEPARTMENT OF COUNTY ENGINEER - --- _ - . 1'- • , .
BUILDING AND SAFETY DIVISION "U.LR SSG G
JOHN A. LAMBIE, County Enggineer .
WILLIAM A. JENSEN, Supt of Building ,LOCALITY
-... NEAREST
FOR PPT TO ,F L CROSS ST.LEGAL �+ /�
DESCFUPTI LO N0/LIC� / O OWNER t• :L / G P
MAIL
BLOCK /TRACT SL/^I ADDRESS Q.
SIZE OF LOT �/,� / NOW ON LOTS CITY �� 'TEL. N0. n
USE OF DISTRICT NO. GROUP MAP PR CESSED
BUI LDINGB ��" ryXI I 8K PG I g
CONTRACTOR 1 / oU L/
ADDRESS �� h �' i CONNECTION DATA
CITY � /"1-' TEL.NO. �(/{-��(t 4- DEPTH /
STATE MANHOLE REFERENCE
44
REGISTRATION NO. �� B COUNTY /
ON OWER
NO. DESCRIPTIDF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
PIETS AND/OR DRAINFPTIC TANK, IELD OR @ $3.00 Y. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. N0. .10H NO. S.
CONNECT ADDITIONAL BLDG.OR i4
WORK TO HOUSE SEWER @ $I.00 TRUNK PERMIT NO. ROAD PERMIT NO. V
ALTER. REPAIR O R ABANDON HOUSE $1 00 STATE ENCROACHMENT Iq
PERMIT NO.
INDUSTRIAL .. U
WASTE APPROVAL W
CHARGES
OWNERS PERMIT $ CONNECTION CHARGE FEE
AUTHORIZATIONTOTAL FEE (/ (� REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- _
TRACTOR TO' CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF / IS- NEWHOUSESEWER
OWNER OR - ,- J CONNECT ADDITIONAL
OWNERS AGENT� BUILDING�OR_WORK -
ADDRESS t SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
AN DTO CO
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION - - - -
STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL [IORYWEL [IWIT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER O OR
PW AND SEWERS. 1 SEWAGE DISPOSAL SYSTEM
HEREBY
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 ES THAT I AM THE LEGAL OWNER OF THE ABOVE BACKFILL SEPTIC TANKS ❑
DESCRIBED RESIDEN 1 PROPERTY.
SIGNATURE SEP. PIT(s) (] CESSPO S ❑ ✓ _
OF PERMITTE � 3
®r VALIDATIOIt-_ ROBERT A. WOOD
CK. H.o. GSHH SUPERVISING MECHANICAL ENGINEER
U',[�5 1 1 4 a .tPft 0 1 1 D 2 5 .(� 0ri
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24650 INSERTS w
°`°64 °° APPLICATION FOR P'
'°"°°�° COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOS L 1.
DEPARTMENT OF COUNTY ENGINEER - - -.
BUILDING AND SAFETY DIVISION emLDIrvG " Ni NGI-AIT
ADDRESS
JOHN A A. LAMBI. DENSE. County Engineer
WILLIAM A. IENSEN. Supt of Building (LOCALITY �� '
NEAREST
FOR APPPC T TO FILL CROss ST. / u
DESCRGAL PTI01 7 N7� / / OWNER
BLOCK TRACT S(/�N/J Y1,6 MAIL ,
// 'ADDRESS
^] AgA-f ""fl 0.OF BLOGS.
SIZE OF LOT / ^�y NOW ON LOT CITY TEL. N0.
USE
BUILDINGS J�+ '- DISTRICT NO. GROUP .MAP PROCESSE Y
BK PG r
CONTRACTOR IV '5�'D _j
1
ADDRESS j
CONNECTION DATA
CITY L TEL./NsO. 4-O T ION O DEPTH
STATIREGISTRATION N0. / ��/ COUNTY .MANHOLE REFERENCE LOWE
NO. OF ORK FEE
HOUSE SEWER CONNECTING TO ` -O
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
PETS AND/OR DRAPTIC TANK. ENFGELDIT OR @ 83.00 Y. CURB P.L. M.L.TO P.L.
cl
IIIOVERFLOW SEEPAGE PITDR
AINFIELD
E%TN.. LESSP00 L. DRYW ELL @ 52.00
HOUSE SEWER CONNECTING TO P.C. 0.
PRIVATE DISPOSAL SYSTEM @_S1.00 CO. IMP, NO. JOB N0. �.
CONNECT ADDITIONAL BLDG.OR y TRUNK PERMIT NO. ROAD PERMIT NO. F"i U
@
WORK TO HOUSE SEWER $1.00
ALTER REPAIR
OSAA ANDDON HOUSE @ $1 00 STATE ENCROACHMENT al
SEWERSYSTEMPERMIT NO. M
INDUSTRIAL U
WASTE APPROVAL w
CHARGES m
OWNER'S PERMIT $ Z 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE C-O REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATErI INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWEa !�n<
OWNER OR /)/) CONNECT ADDITION.L
OWNERS AGENTS/' BUILDING OR WORK
-, ADDRESS SEPTIC TANK,SEEP.PITS)
ANO/OR DRAINFIELD _
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS.APPLICATION - -
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER.REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES.COUNTY AND STATE OF DISCONNECT
HO PLUGAUSE D '
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENT( P OPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE SE PIT(5) ❑ CESSPOOLS ❑
OF PERMITTE
®° VALIDATION ROE ERT A. WOO
CK.. M.O, GSH SUPERVISING MECHANICAL ENGINEER
V'.c.05 1 1 R?fi 1 (j 1 0 U 5 .0 0