HomeMy Public PortalAbout5729 ENCINITA AVE_Sewer__ [EBpa )z-aB APPLICATION FOR PERMIT
Tan eazD COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS A Z O
COLEMAN W. JENKINS, SUPT. OF BUILDING
LOCALITY
NEAflEST
FOR APPLICANT TO FILL IN CRO6s ST'
GAL
DESCRIPTION LOT No. r�CyL OWNER Q /y
MA L
BLOCK TRACT ADORE .J 1 top
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF . DISTRICT NO. GROUP MAP P OLESSED BY
BUILDINGS /�/ G �/J/ Bj'.
CONTRACTOR i / . -1/QO /\ , BL `� / Jp
ADDRESS \/ CONNECTION DATA vvvWll//✓✓✓
CITY ( u TEL. NO. S 6 STATION �] DEPTH
STATE L C / / UPPC
Be
NO. $O LLAS6 ` MANHOLE REFERENCE / sQ Q LpWER
NO. DESCRIPTION OF WORK FEE TYPE OFC TION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. C RB P.L. M.L.TO P.L.
PUBLIC SEWER ! $5.D0 O
SEPTIC TANK,SEEPAGE PIT OR JOB NO'
PITS AND/OR GRAINFIELD 0 SIO.00 CO.IMP. NO. JOB NO. '
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 0 53.00 TRVNN PERMIT NO. gOAO PERMIT NO. D_
O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT uv4 ps[II[xs RECORD.INSTR.NO. PATE V
WORK TO HOUSE SEWER 0 $3.00
OVERFLOW SEEPAGE PIT.GRAINFIELD O
E%TN..CESSPOOL DRYWELL.M A NHOLE 0 55.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING W
SEWER OR DISPOSAL SYSTEM Q 13.00 STATE ENCROACHMENT CL
PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT f z o0
AUTHORIZATION 70TAL FEE CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH TME HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO-CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_ ; ; -
OWNEROR NEW HOUSE SEWER /I
OWNERS AGENT_
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTICTANK.SEER PIT(S)
AND/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORVwEIL ❑ I
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR.SEWER OR
ENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAG E DISPOSAL SYSTEM
LIC / I
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND /
RESIDE IN. THE ABOVEPESCRIBW RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
/I
SIGNATURE BACKFILL SEPTIC TANKS ❑ /' [
OF PERMITTEE
SEEP.PITIS) ❑ CESSPOOLS ❑
VALIDATION JACK R. ALLEN
cK.
M.0. CASH SUPERVISING MECHANICAL ENGINEER
(` 6 4 0 9� AUG20 1 0 D 7.00';.