HomeMy Public PortalAbout5740 ENCINITA AVE_Sewer__ U
CE808 APPLICATION FOR PERMITU .
eeoe (1-119APPLICATION
OF LOS ANGELES
SEWER—SEWAGE DI POSAL
DEPARTMENT OF COUNTY ENGINEER -_.,.- ..
BUDDING AND SAFETY DIVISION BUILDING /cif-
JOHN A. LAISIBIE. County En inner U
CASSATT D. GRIFFIN, Sup t of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS STLEGAL .
t
DESCRIPTION LOT NO. / G OF OWNER p J.�., y
BLOCK TRACT i \ MAIL n
ADORERS :.o'iiKY
NO.OF BLDGS. ,
SIZE OF LOT NOW ON LOT CITY O' TEL. N0.
USOF
BUE DINGS pY ' ./�JIW DISTRICT NO. GROUP MAP P" ESSED B
_ BK PG
CONTRACTOR ,.yam
ADDRESS CONNECTION DATA -
CITTO TEL.NO. STATION lZ DEPTH
STATEMANHOLE REFERENCE _5' PER
REGISTRATION N0. 1'Y" Y '❑ COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OFC TION LENGTH FROM O
SEPTIC TANK,SEEPAGE PIT OR Y. RB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD C& $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
E'TN
..CE SSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO. JOB ND.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT N0. Z L
WORK TO HOUSE SEWER @ 51.00
SEWER OR DISPOSAL SYSTEM HOUSE @ $1.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE CJT� REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INS ECTOR'S SIGNATURE
TO THE PUBLIC SE ER.
SIGNED THIS DAY OF— NEW HOUSE SEWER
OWN
ER ORCONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP. PIT(5)
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 I] DRYWELL 0
WITH ALL COUNTY ORDINANCES AND STATE WS-REGULATING TER,REP
AIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY T 1 AM PROP R REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS RE0U1 Y LOS A GEL S COUNTY AND STA OF ABANDON HOUSE SEWER
CALIFORNIA OR T 1 AM TH LEG L OWNE THE ABOVE
DESCRIBED RESIDE t PROPERT BACKFILL SEPTIC TANKS ❑
SEEP. PIT(S) ❑ CESSPOOLS
SIGNATURE
OF PERM C
ROBERT A. WOOD
0.
M.o. CASH SUPERVISING MECHANICAL ENGINEER
I
alo 2 9 1 5 J fil 2 8 1 C 5.0 0 I1',