HomeMy Public PortalAbout5936 ENCINITA AVE_Sewer__ CEBOB 10.62
76ABD APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER _
BUILDING AND SAFETY DIVISIONBD UDING t r
JOHN A. LAMBIE, County Engineer ADoREss V {j
WILLIAM A. JENSEN, Supt of Building
LOCALITY
NEp REST
FOR APPLICANT TO FILL IN CRO55 ST
LEGAL
DESCRIPTION LOT NO. 1I •J J O
MAIL
BLOC< TRACT AOOAE S
F7 n• � / /O NO. OF BLOGE,
512 dF/LOT DLII Is NOW ON LQOT CITY TEL NO.
USE OF C/, pISTRICT NO. GROUP MAP PROC )BY
BUILDINGS BK
PG
CONTRALTO sj O 7X /07
ADDRESS! r p CONN
^ECTDATA
CITY �.(/ - TEL. NO. O C STATION 1 l,v , ` DEPTH
STATE ✓ C_ UPPER
/ MANHOLE REFERENCE /^
REGISTRATION NO. / O/ COUNTY
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTIONPL LENGTH FROM
HOUSE SEWER CONNECTING TO O Y. CURB . M,L.TO P.L.
PUBLIC SEWER @ SS...
REPT IC TANK.SEEPAGE PIT OR / / 0 P.C.NO.
PITS pNO/OR DNA I NEIELD ® SIO.00 CO.IMP. NO. O JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRI VAT.DIEPOE AL SYSTEM 53.00
CONNECT ADDITIONAL SLOG,OR AFFIDAVIT MY •s[N[ RECORD.INSTR.NO. DATE
WORK TO HO USE SEWER 53.00
OVERFLOW SEEPAGE PIT.GRAINFIELD
E%TN..CESSPOOL.DRIWELL.MANHOLE $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST,WIDENING
SEWER OR DISPOSAL SYSTEM 53.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OV✓NER"S P£AMIT 5 z 00
AUTHORIZATION TOTAL FEyC Ol� CONNECTION CHARGE FEE
1 HAVE AT THIS OATS A CONTRACT WITH THE HEREIN NAMED LONG REIMBURSEMENT FEE
TRACTOR TO IBE THE ABOVE DESCRI ED EXISTING OWELLI G
TO THE PUBLIC C BE
APPROVALS GATE INSPPCTO SIGNATURE
SIGNED THIS OF 1
OW NEO OR NEW HOUSE WE OWNERS AGENT CONNECT ADDITIONAL J
BVILOING OR WORK
ADDRESS
SEPTIC TANK,SEEP.PITIS)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ANO/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAV 1 AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR,SEWER OR
LICENSED AS REOUIREO/ LOS ANGLES COV NTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT ✓ 1 THE LEGAL OWNER OF„.'AND INTEND TO DISCONNECT PLUG
AND
RESIDE IN, THE ABO OE.0 £D RE IDEN�p OPERTY. gBgNDON HOUSE SEWER
SIGNgTV RE /�j B,CKFILl_SEFTIC TANKS ❑
OF PERMITTEE /fl ❑
SEEP.PIT(31 ❑ CESSPOOLS
VALIDATI ROBERT WOOD
CK. ALO. cgsH SUPERVISING MECHANICAL ENGINEER
LAC09 6 3 5t2 AUG-30 1 0 D 7.0.0 ,a