HomeMy Public PortalAbout6149 ENCINITA AVE_Sewer__ J&S42D
E-66 APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Depratment of County Engineer
County Of LOB Angeles. BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
m CASSATTD. GRIFFIN, SUPTOFIEUILCHM0 LOCALITY
FOR APPLICANT TO FILL IN 'Ross"s si. 1
LEGAL �f OWNER J
DESCRIPTION LOT N0. �G.
ry,) MAIL
BLOCK TRACT % y ADDRESS
lil( N0. OF BLDGS. CITY TEL. N0.
SIZE OF LOTT�7//// NOW ON LOT
USE OF DIST
BUILDINGS RICT N0. GROUP MAP
CONTRACTOR LBK / 17
PG
CONNECTION DATA W�
ADDRESS r
V \
STATION DEPTH
CITY %TEL. NO. '
` MANHOLE REFERENCE UPPER
LOWER
REGI TRATION NO. /y/I H COUNTY O
NO. DESCRIPTION OF WORK FEE TYp'OF CONNECTION LENGTH FROM !�J
HOUSE SEWER CONNECTING TO Y, CURB P.L. Y.L. O P�T 1
PUBLIC SEWER @ $3.50 t
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR GRAINFIELD @ $3.00
R OVERFLOW SEEPAGE PIT.DRAINFIELD P.•Q" 0.
Al
_ EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $ 2.00 CO. IMP. NO, 109-NO.
HOUSE SEWER CONNECTING TO I,Y P-i
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG.OR STATE ENCROA ENT '� f
WORK TO HOUSE SEWER @ $ I.00 '� PERMIT NO.
ALTER.REPAIR OR ABANDON HOUSE INDUSTRIA +' L;/ L
SEWER OR DISPOSAL SYSTEM @ $ 1.00 I WASTE APP L r /
T
ARGE r
CON C ION CHARGE FEE -
OWNER'S PERMIT S 1 00 —
AUTHORIZATION ITOTAL FEE cx `, REIMBURSEMENT FEE
HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALSAT INS ECTOR.SGIGN ATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING /
TO THE PUBLIC SEWER. - NEW HOUSE SEWER L
SIGNED THIS DAY OF 19_ CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
VIITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEVERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTEREU AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AFI THE LEGAL OW ER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE _SEEP. PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATION ROBERT A. WOOD. CHIEF PLISG. INSPECTOR
CK. Y. 0. CASH
LAC03 1 3 0 m JL4 2 3 1 A 2.0 0 M