HomeMy Public PortalAbout5715 ENCINITA AVE_Sewer__ 14650 INSERTS
CEAAPPLICATION FOR
TenS4 PERMI 1
eaz0 COUNTY OF LOS ANGELES3.
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION gAlc
/
fOHN A. LAMBIE. County Engiaeor ADDRESS
WILLIAM A. JENSEN, Supt of Binding LOCALITY
NEAREST
PLIC T TO FIIL IN A cxoss sT.
/R b ./
RL
DESC�LEGAL V OWNER �+ G �./
.OT 10�' n I
BLOCK TRACT S(/�N �/ JE MAIL
ADDRESS b
NO 0 BLDGS.
SIZE OF LOT NOW ON LOT CITY G TEL. N0.
USE OF
BUILD
INGS DISTRICT NO. GROUP MAP PROCESS//EMMM//I�I''Y
O IBK P� .I l
CONTRACTOR
ADDRESS / J/ 3 CONNECTION DATA
CITY TEL.NO. ` STATION7L70, 91' DEPTH
y STATE MANHOLE REFERENCE PPER
REGISTRATION NO. '/ 04'9'
/s / B COUNTY
NO, DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM r
PETS AND/OR DRAINFPTIC TANK, GELDIT OR @ S3.Do Y. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN..CESSPOOL. DRYWE LL @ S2.DO
HOUSE SEWER CONNECTING TO ��JJ P.C.ND. _
PRIVATE DISPOSAL SYSTEM @ S1.00 CO. IMP. NO. 0.'. JOB NO. W
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. S U
WORK TO HOUSE SEWER @ $1.00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT a
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO. O
H
INDUSTRIAL U
WASTE APPROVAL w
CHARGES LO
OWNER'S PERMIT $ �-r2 00 CONNECTION CHARGE FEE
,- F7
AUTHORIZATION TOTAL FEE 0r0 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 ' 19_ NEW HOUSE SEWER
OWNER OR 1C..l CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP.PITS)
ADDRESS 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. 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 RESIDENTI L ROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP. PIT(,) ❑ CESSPOOLS
OF PERMITTE , B'h Qui
®r
VALIDATION,--) ROB RT A. V%fbbb
CK. m.0. Cf.:-H ' SUPERVISING MECHANICAL ENGINEER
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