HomeMy Public PortalAbout5828 3/4 ENCINITA AVE_Sewer__ OB
CSBoe-5 APPLICATION FOR PERMIT
se .ee COUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUDRESS !:1
ADDRESS
JOHN A. LAMBTE, COun1Y Engine"
CASSATT D. GRIFFIN, Sup'1 of Building LOCALITY
NEARESTFOR APPLICANT TO FILL IN
CROSS ST. /
LEGAL
DESCRIPTION LOT NO. t S O OWNER
BLOCK TRACT MAIL
ADD
NO.OF SLOGS. r
SIZE OF LOT-5"Q X NOW ON LOT CITY C� TEL.NO.
USE OF 1
BUILDINGS DISTRICT NO. GROUP MAP P GESSED
BK PG
CONTRACTOR
ADDRESS �d _ ONNECTIO DATA
CITY TEL. NO. 1 STATION DEPTH
3 (� STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. D COUNTY LOWER
NO. DESCRIPTION 0 WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00
SEPTIC TANK, SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PITS AND/OR DRAINFIELD @ $3.00 Y• CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C. NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
ALTER. REPAIR O R ASYSTEM HOUSE @ $I.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 �0f0s1 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE oD REIMBURSEMENT FEE
I
HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS GATE INSPECTOR'S SIGNATURE
HAVE
TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THISSAY OF Iy_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERSAGENT (� BUILDING OR
SEPTIC TANK,SEEP. PIT(S)
ADDRESS AND/OR DRAINFIELD
1 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 R TERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES C, U TY ND SPATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT M< M E LEGAL 0 1 THE A]
DESCRIBED RESID NTIA P P Y. SEEP FPiT(SEP❑C CESSPOO ❑
SIGNATURE
OF PERMITTEE
®r. ATION ROBERTA.WOOD
_.
M.0. CASH SUP6RVIGING MECHANICAL ENGINEER
AC,3 6 0 9 9 U KAY 41 0 A 3.0 0