HomeMy Public PortalAbout5719 ENCINITA AVE_Sewer__ r DEFARrMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING7
ADDRESS6 �q CM—LO`
FOR APPLICANT TO FILL IN LOCALITY �, 1�lepBUILDING C
ADDRESS _f 19 -C-NCINtTA I�.Mr-_. NEAREST.
CROSS ST �J�(�yL.l.��/
LOCALITY TL M PL I= CI-rY DISTRICT N0. SERIAL NO. PERMIT NO.
CROSS ST. Avs �
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OWNER ((jj 1�r,( �Y/[�U/f{�J111V/// (�I
ADDRESS I-1�n ENeINIT�A AVE• .USE 20NE OCCUPANCY BK MAP
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CITY TCMPJ- _ 0,IrCTEL.NO: I I-+_O_;-0 V I l � 7 '
CONTRACT- ��
CO.IMP.NO.
ADDRESS r
JOB N0.
CITY .I
TRUNK PERMIT N0.
REGISTRATION N STATE
�! ® COUNTY ROAD PERMIT N0.
LEGAL wNNV VICW'
DESCRIPTION LOT NO. STATE ENCROACHMENT
I I O
BLOCK TRACT �• INDUSTRIAL
0 1 -i JIa� WASTE APPROVAL
512E OF LOT N0.OF BLDGS.
NOW ON LOT CHARGES -
#' USE OF 1
BUILDINGS CONNECTION CHARGE FEE
N0. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE \
HOUSE SEWER CONNECTING TO" ,1h A �
PU 13LICSEWER o S 3.50 VV RECEIPT NO. I \TE/ IBV
i PRIVS TE DISPOSAL SYSTEM TO 1-00 -SEWER CONNECTING
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO ATE \ IBY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK.SEEPAGE PIT OR /
SPITS AND/OR GRAINFIELD 2.00 STATION Z-}3 � ' (� DEPTH (�
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 ('/ //''''' MANHOLE REFERENCE.
UPPER _LQW.ER.
TYPE OF CONNECTION LENGTH FROM
OWNERSPERMIT S 1 OU CURB 4C M.L.TO P.L. � d
AUTHORIZATION TOTAL FEE [1 S-G
I HAVE THIS DATE CONTRACTED HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVEOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
' DWELLING TO TH EL p�U BLIC SEWER
SIGNED THIS......I_.j._--,-D/+Y OFj�.. _... _. -. -._.... 19_ NEW HOUSE SEWERf
OWNER OR "IWO rAI�.'.h LI`N' - CONNECT ADDITIONAL
OWNERS AGENT
..1..1...G..--_...-.- ...... /] ...... BUILDING OR WORK
SEPTIC TANK.SEEP.
ADDRESS......_D.--1-{-.1_ -..- -�SdI.YSt---_--- AND/OR DRAINFIELD IT(S)
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL DRYWELL E]
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I DISCONNECT PLUG AND
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN- '
ER OF THE ABOVE DESCRIBED RESIDEN1yAtrT7MP E7R Y. BACKFILL SEPTIC TANKS r,
tV/ I,//�1JA SEEP.PIT(S)o CESSPOOLS J/jX11-411
SIGNATURE - ---- „ --�(�Z/�"'�+"V
OF PERMITTEE.:. ... y(y�,d
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