HomeMy Public PortalAbout5746 ENCINITA AVE_Sewer__ �/i /✓l/�L E G / Tx
CEBOB 3.B2 APPLICATION ATION FOR PERMIT
TBABazD COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER — - -
BUILDING AND SAFETY DIVISION eu1LDING
JOHN A. LAMBIE. COUNTY ENGINEER ADD REss
COLEMAN W. JENKINS. SUPT. OF BUILDING
LOCALITYf
NS
FOR APPLICANT TO FML IN `ROROSSS ST.
LEGAL
DESCRIPTION LOT NO. r2 �Q` OJ ! (7 ( !O OWNER /
MAIL
BLOCK TRACT 5/aGl AGC ESS
NO. OF BLOCS.
SIZE OF LOT NOW ON LOT CITY TEL NO _
USE OF DISTRICT NO. GROUP MAP E ~ PROCESSED BY
BUILDINGS
BK PG
CONTRACTO _ �� �J C ,
ADDRESS n CONNECTION DATA
STATION DEPTH ..�
CITY TEL NO. (p
STATE LICMANHOLE REFE ENCE r } UPS
LICENSE NO, .LA55 (N (y
NO. .DESCRIPTION OF WO K FEE I TYPE OF CO TION LENGTH FROM
/ HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. Q/ a
PUBLIC SEWER 85.00 {.+L�
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. O
PITS AND/OR DRAINFIELD $10.00 CO.IMP. NO. 13 72- JOB NO.O.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO, 17 9 C
PRIVATE DISPOSAL SYSTEM 83.00 A(,�) O
CONN ECT ADDITIONAL BLDG.OR AFFIDAVIT AIY NUIx RECORD, INSTR,NO,
DATE F
WORK TO HOUSE SEWE R @ 83.00 v
OVERFLOW SEEPAGE PIT.DRAINFIELD W
E XTN_CESSPOOLDRYWELL.MA NHO LES S. d
WIDENING
ALTER,REPAIR OR ABANDON HOUSE HWY. 0R ST. '
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT
PERMIT NO.
-ill- INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT sl z 00 CHARGES
AUTHORIZATION TOTAL FEE {{::✓✓q0 CONNECTION CHARGE FEE
HAVE AT THIS GATE A CONTRACT WITH THE HEREIN NA D CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DREIMBURSEMENT FEE
WELLING APPROVALS
TO THE PUBLIC SEWEfl. DATE $PECTOR' SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR - NEW HOUSE SEW ER
OWNERS AGENT_ CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.SEEP, PIT(S)
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION PND/OR GRAINFIELD
AND STATE THAT THE ABOVE ICORRECT AND ACOMPLY
WITH ALL COUNTY ORDINANCES
S ANO STATE LAWSWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYW ELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED 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 DESCRIBED RESIDENTIAg PROPERTY ABANDON HOUSE SEWER
SIGNATURE
OF PERMRTE BACKFILL SEPTIC TANKS ❑
SEEP.PITISI ❑ CESSPOOLS
^V
M.O. CASH ALIDATION ALLEN
SUPERVISING
NG MECCHH ALLEN
ENGINEER
CK.
IN
LALO5 4 4 9- JUL12 1 0 D 7,00-