HomeMy Public PortalAbout5734 ENCINITA AVE_Sewer__ a
CE808- APPLICATION FOR PERMIT -<
seoe.e-sa COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER --... ." :.
AND SAFETY DMSIONBUILDIN7G -
BUILDING IOHN A. T.AMBIE, Ceuatp EgindurDDRESCASSATT D. GRIFFIN. Supt of Building L000.LI.._,: NEARESFOR APPLICANTTOFiLi. IN CROSS S
LEGAL OWNE
DESCRIPTION LOT N0. J
MAIL
BLOCK TRACT % ADDRESS
N0.OF BLDGS.
SIZE OF LOT � /L � O NOW ON LOT CITY TEL. N0.
USE OF .. . - ..e ., ... ..
BUILDINGS -i DISTRICT N0. 'GROUP MAP PROCESSED BY
CONTRACTOR`
ADDRESS ` CONNECTION DATA
TEL.N0, v STATION �� P `� DEPTH 1
REGISTRATION NO. f COUNTY MANHOLE REFERENCE / •��^ / UOWER
NO. DESCRIPTION OF WORK \ FEE -
HOUSE SEWER CONNECTING TO I
/ PUBLIC SEWER @ $3.00 LfO
SEPTIC TANK, SEEPAGE PIT OR - TYPE OF N LENGTH FROM 1 /
PITS AND/OR DRAINFIELD ® $3.00 Y. URB P.L. M.L.TO P.L. (>
OVERFLOW SEEPAGE PIT. DRAINFIELD
EXTN.,CESSP00 L,ORYW EL L.MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM $1.00 CO.IMP.N0. � y JOB N0.
r CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
ALTER ORDISPOSALSYSTEM HOUSE $I 00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00 :1 CONNECTION CHARGE FEE n
AUTHORIZATION TOTAL FEE CIO REIMBURSEMENT FEE �,>y
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER j� -
SIGNED THIS 9nnAY OF `� jg+� ' NEW.HOuSE SEWER 1`3kt-/I
ti OWNER OR CONNECT ADDITIONAL
OWNERS AGENT �'� /� BUILDING OR WORK
G� GL Y SEPTIC TANK,SEEP, PIT(S)
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
1 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 GAL OWNER OF THE ABOVE TANKS 11 �/ / `
j DESCRIBED RESIDEN7I PROPER SEEPBACKFPIT(S)ILL POC CESSPOOLS S&� /YOT�/P(f'P�-Ky,
SIGNATURE
OF PERM ITTE
VALIDATION ROBERT A.WOOD
IS.0. WB SUPERVISING MECHANICAL ENGINEER