HomeMy Public PortalAbout6261 ENCINITA AVE_Sewer__ E.6n
Sa APPLICATION FOR PERMIT
eDIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer - .,:• ,.
County of Los Angeles BUILDING /
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS r
® CASSATT O. GRIFFIN, SUPT GF BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FILL IN cnoss Sr.
LEGAL ( '
DESCRIPTION LOT NO.j OWNER
// MAIL ,
BLOCK TRACT .J'�e ADDRESS
NO. Of BEGGS. CITY ------ TEL. NO.
SIZE OF LOT NOW ON LOT
USE OF DISTRICT
BUILDINGS NO. GROUP MAP
...r+ BK .. PG
' CONTRACTOR ✓ C /Y .,
ADDRESS CONNECTION DATA
J
J p G G _,. STATION DEPTH
CITY TEL. N0. —i— MANHOLE REFERENCE
[� STATE J
REGISTRATION NO./.�. Q �j IJ COUNTY '��
No. DESCRIPTION OF WORK FEE S
HOUSE SEWER CONNECTING TO TYPE OF TION - LENGTHTO PFROM.L. _ �f
PUBLIC SEWER @ S 3.50
.S CURB M.L. QI(
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR GRAINFIELD @ $3.00 l 2 / _
OVERFLOW SEEPAGE PIT,DRAINFIELD / � P. C. NO.
EXTN..CESSPOOL,DRYWELL,MANHOLE @ $ 2.00 CO. IMP. NO. JOB N0.
HOUSE SEWER CONNECTING TO II !)
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT ND OC,
CONNECT ADDITIONAL BLDG.OR a STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $ 1.00 PERMIT NO.
ALTER, REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT
$ D
AUTHORIZATION TOTAL FEE `/� (,/I REIMBURSEMENT FEE
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- ' APPROVALS DATE INSPECT R'SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. - //. : NEW HOUSE SEWER
SIGNED THIS DAY OF tU CONNECT ADDITIONAL
OWNER OR _J BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
HEREBY KNO THAT 1 HAVE READ THIS APPLICATION CESSPOOLIJ DRYWELL❑ '
ANO STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I M THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDEN�AL� OPERTY, y BACKFILL SEPTIC TANKS❑\� n /J
N SEEP. PIT(S) CESSPOOLS pQ �(f� /• I
SIGNATURE �j,
OF PERMITTEE
JOHN A. LAM IE, COUNTY ENGINEER ~' ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
VALIDATION '
CN. N.0. q5N
11238U— OCT 1.1 4
450 ,m