HomeMy Public PortalAbout6002 ENCINITA AVE_Sewer__ � ✓
G
cEsos APPI�ICATIONV4OR PERMIT
eeos a-Fa COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER - -- -_ - --- ---- I
BUILDING AND SAFETY DIVISION ADADSA A. LARIFFI , Supt of BulleCASSATT D. GAiFPIN, Supt of Iluildinq LOCALITYNEAREST / JFOR APPLICANT TO FILL IN CROSS ST.LEGAL n �'DESCRIPTION LOT NO. / OWNER A BLOCK TRACT MAILWolf
ADDRESS . -111y _T
NO.OF FLOGS, �1FSIZE OF LOT 3�) �� NOW('ON LOT QJ CITY TEL. NO. A F
BUEL INGS OF G4f 3�.oL{}�} .�i�' ' DISTRICT NO. GROUPS BK MAP PG PR LE33ED
CONTRACTOR
aooaess CONNECTION DATA
CITY �y / TEL.NO. Y2/ Y. STATION DEPTH
01 .� ! STATE MANHOLE REFERENCE UPPER
REGISTRATION N0. 10 a� COUNTY LOWER
No. DESCRIPTION OF WORK FEE / O
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPr OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00 -
OVERFLOWSEEPAGE PIT.DRAINFIELD
EXTN.. CES SPOOL. GRYW ELL @ S2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @SLOO CO.IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.ORTRUNK PERMIT NO. ROAD PERMIT NO.
_ WORK TO HOUSE SEWER @Sim
_
ALTER.REPAIR
OS@ $100
PAIIRRA ABANDON HOUSE STATE ENCROACHMENT
SEWER PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OV/NER'SPERMIT g 2 00 CONNECTION CHARGE FEE
_ AUTHORIZATION TOTAL FEE O-Z) REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
I TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
' SIGNED THIS DAY OF-19—19— NEW HOUSE SEWER
OWNERS A [Yh. l 91 �C S CONNECT ADDITIONAL
RWORK
OWNERS AGENT _//�!l if)_ %r �3 CONNECT
WORK ell,._
SEPTIC TANK,SEEP. PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I 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 TkLT!1 AM PR,027LY ggEEGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REOUIRF,D,AHY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAI/1 AM THEPER Y. LEGAK OWNEROF THE', ABOVE BACKFILL SEPTIC TANKS ❑
DESCRIBED RESIDEN, L PROC?'�`�•�"^' SEEP. PIT(3) ❑ CESSPOOLS ❑
SIGNATURE
OF PERMITTE>•
01 / ,jV'ALIDATION"-\ ROBERT A. WOOD
CK. Y 0. GASH } SUPERVISING MECHANICAL ENGINEER
u._ � 225 � 11tY Z o - 3 .00 � .