HomeMy Public PortalAbout6027 ENCINITA AVE_Sewer__ 6J2D 2/J°
76A APPLICATION FOR PERMIT
JfiA , f
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL IILJI1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 1 BUILDING
7
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
COLEMAN W. JENKINS. SUPT. OF BUILDING
LOCALITY N
FOR APPLICANT TO FILL IN NEAREST
CROSS $T.
(PRINT OR TYPE ONLY)
DESCRIAL PTION LOT NO. �' J � OWNER tlE�i` U�CT E!EAL-S
MAIL
BLOCK TRACT OADORE p
Q { IFrS C��Sy�L/lr6J
SIZE OF LOT NOW ON LOT /CITY TEL. NO./1-1-J3Q-3C,S
USE OFR Cr pISTRICT NO. GROUP CLASS MAP PROCESSED BY
BUILDINGS ✓[i
/,^�F y/ y / /l`f -/'
BK PS
ZONTRACTOR �� Q� l�/L�jl �(,. l�' V ./
ADDRESS 'yy �A �`6 5 1Y%i�/(r �T /CONNECTION DATA
CITY /'/J/ �C��./i TEL. NO. J ��-I�� �� STATION L DEPTH
LICE
`3 9 s- LIC
LICENSE NO. 7 n CLASS MANHOLE REFERENCE
_ OWER
NO, DESCRIPTION R ON EC WORK FEE TYPE OF CO IGG=ION L NGiH F OM
HOUBE SEWER CONNECTING TO Y. URB P.L. M.L,TO P. p
PUBLIC SEWER ® $S.00
SEPTIC TANK,SEEPAGE PIT OR 3 '-
CO.IMP.NO. JOB NO.
PIT$AND/OR GRAINFIELD ® 110.00 �j
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. �{ a
PRIVATE DISPOSAL SYSTEM f3.OD 1
CONNECT ADDITIONALBLDG.OR AFFIDAVIT MY 5[R[ RECORD.INSTR.NO, DATE O
WORK TO HOUSE SEWE R ® 13.00 U
OVERFLOW SEEPAGE PIT,GRAINFIELD
ALTER,ESSPOOOR PYWELL.ABANDON HOUSE 6 15.00 HWY.OR ST.WIDENING O
SUER,REPAIR OR ABANDON ROUSE
SEW ER Ofl DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT
U
PERMIT NO. W
INDUSTRIAL 1
h
WASTE APPROVAL "L
OWNERS PERMIT S z oo CHARGES
AUTHORIZATION I TOTAL FEE -3Io CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN ZED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO TME PUBLIC BE ,;NR- APPROVALS DATE INSP OR'S NATURE
SIGNED THIS' DAY OF
OWNER OR / NEW HOUSE SEWER
OWNERS AGENT +
yy /j CONNECT ADDITIONAL
AGO RE55 W '-70I J /O BUILDING OR WORK
SEPTIC TANK.SEEP.PIT ISI
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ANO/OR DRAINFIELO
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY _
WITH ALL COUNTY-ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. .. CESSPOOL ❑ DRYWELL ❑
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AGID STATE OF sCWAGE DISPOSAL SYSTEM 1
CALIFORNIA OR THAT I AM THE LEG. OWNER OF. O INTEND TO DISCONNECT PLUG AND
RESIDE IN, TME ABOVE OE IBE� SI pENT1AL P PERTY.
ABANDON HOUSE BEWR
SIGNATURE
OF PERMRTEE I BACKFILL BE PTIC T ANKS ❑ /
_ - - Al.-PIT I51 ❑ CESSPOOLS ❑ 7/
i/ C VALIDATION JACK R. ALLEN
M.O. CASH
SUPERVISING MECHANICAL ENGINEER
f^_ 165 1610 D 7000