HomeMy Public PortalAbout5724 ENCINITA AVE_Sewer__ aE50BAA']Z APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER WAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILD LNG 5724 Encinitas
AODRESS
emp e ulty, C?irormia
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS $
LEGAL Patt enelli
DESCRIPTION LOTNO. OWNER
f /�/ MAIL
BLOCK TRACT (/1 S ADDRESS5724 Eocinitms
Y NO. OF BLDGS. Temple Gjt TEL. ND. 266 4081
512E OF LOT NOW ON LOT CITY 1 .
USE OF I BK PG
DISTRICTNO. GROUPI MAP SSEO Y
BUILDINGS y^
CONTRACTORGus Goldin Ent. Alcadia Plmg J, Vo
ADDRESS 170 W. Live Oak CONNECTION DATA
CITY Arcadia, La. TEL. NO. 44b 12BU STATION DEPTH
STATELICENSE
250046 LIC MANHOLE REFERENCE UPPER
LICENSE NO. CLw55 LOWER
NO, DESCRIPTION OF WORK .FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER a P,C.NO, d
SEPTIC LANK.SEEPAGE PIT OR CO.H.P. NO. JOB NO.
PITS gNpIOR DRAINFIELD @
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
nRIVATE DISPOSAL SYSTEM
_ a C
CONNECT OUSE SEW BLDG,OR AFFIDAVIT My E5141KI RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER F
OVERFLOW SEEPAGE PIT.wIFL NL
E%TN..0 LDRWMANHOLE @
REPAIR LWJ
HWY.OR ST,WIDENING D.
SEWER O^^"""' ' V STATE ENCROACHMENT N
Z
PERMIT NO.
.'U TRIAL
WASTE APPROVAL
OWNER'S PERMIT s CHARGES
Li�
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
REIMBURSEMENT FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER, DATE INSPECTOR'S SIG NATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER _
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK R
ADDRESS
SEPTIC TANK, PIT(5) '
HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION AND/OR GRAINFIELD
AN CSTATE THAT THE ABOVE 15 CORRECT AGREE COMPLY
WITH ALL COUNTY ORDINANCES AND STATETE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYWELL ❑
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE Er
RIBED RESIDEN IPL PROPERTY. ABANDON HOUSE BE WER
SIGN ❑
OF ATURE PERMRTEE BACKFILL SEPTIC TANKS
SEEP,PITI51 Cl CESSPOOLS ❑
l I
VALIDATION
CK. Id.O. p5N
�dGL.tii �J COMPENSA-ION
POLICYHOLD� 7 9 1�P�EC 21 1 9.0 0 n
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