HomeMy Public PortalAbout6204 ENCINITA AVE_Sewer__ 71&j6G22)'CEBDB A-7/76 APPLICATION FOR PERMIT
SEWER—SEWAGE DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN DISTl ICTNO. BBDUP MAP PROCESSED BY
BVILDING f /� Y �� /7
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LOCALITY T�'!�=/�E �� CONNECTION DATA
NEAREST ... /y� p� STATION DEPTH
CROSS ST. \./%�"J�M/L Q
UPPER
MANHOLE DEFERENCE --
1 J LOWER
OWNER TYPE OF CONNECTION .
CITH OM
MAIL CURBPr,TO P.L.
ADDRESS .
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PNO.
CIT 'TEL NO. Co.IMP. NO. JOB
NO,
LEGAL TRUNK PERMIT NO, ROAD PERMIT NO.
DESCRIPTION LCT NO.
AFFIpAVIT Yu I EASEMIX, RECORD.INSTR.NO. DATE
BLOCK TRACT
NO. OF BLOCS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OFSTATE ENCROACHMENT
BUILDINGS PERMIT NO.
CONTRACTOF
INDUSTRIAL Q
/ J-+ .L`J WASTE APPROVAL a
A DRE5. z ) CHARGES Q
CONNECTION CHARGE FEE U
CITY
O.
STATEG S LIC REIMBURSEMENT FEE C.
LICENSE NO. a / CLASS
NO. 1 DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE W
HOUSE SEWER CONNECTING TO a
PUBLIC SEWER N
SEPTIC IANK,SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR ORAINFIELD ® CONNECT ADDITIONAL Z
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM ® SEPTIC TANK.SEEP,PIT(S)
CONNECT ADDITIONAL BLDG.OR AND/OR GRAINFIELD
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL ❑ DRYWELL Cl
EXTN_CESSPOOLORYWELL.MANXOLE
ALTER.REPAIR OR ABANDON HOUSE I ' ` 'l ALTER,REPAIR,SEWER OR
SEWER OR DISPOSAL SYSTEM ® Y J v SEWAGE DISPOSAL SYSTEM
DISCOryNECT PWG AND
ABANDON NOUSESEWER
BACKFILL SEPTIC TANKS ❑
SE EP.PIT I5) E (CESSPOOLS ❑
OWNER'S Issuance Fees S L�
AUTHORIZATION X5TATE ACKNOWLEDGE THAT HAVE READ THIS APPLICATION
TOTAL FEE LU AND STATE THAT THE ABOVE IS COO RECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
HAVE AT THIS DATE A CONTRACT WITX THE HEREIN NAMED CON PLUMBING AND SEWERS.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR '
TO THE PUBLIC SEV`[R. / LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF
SIGNED THIS OF `� 19 CALIFORNIA OR THAT AT 1 AM T LEGAL OWNER OF, AND INTEND TO
OWNER OR RESIDE IN. THE ABOVE IB RESIDENTIAL PROPE T
'6WNER$AGENT '✓'r SIGNATURE
�i OF PERM
TTTEE
LIDATIOff
CC M.D. CASH
0 0 6�1-AUG. 5 1 0 D 9.0 0 "73