HomeMy Public PortalAbout6263 ENCINITA AVE_Sewer__ �, I T
76A6420 0-63 APPLICATION FOR PE IT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPO AL
DEPARTMENT OF COUNTY ENGINEER _
BUILDING AND SAFETY DIVISION BuliDlnc U
JOHN A. LAMBIE. County Engineer ADDRESS
WILLIAM A. ]ENSEN. Sup'1 0l Building
LOCALITY
NE4REST
FOR APPLICANT T FILL IN CRD55 5T.
EGAL 7
PRE
DESCRIPTION LOT NO. / OWNER
MAIL
BLOCK TRACT Q D ADDRESS
NO. F BLO GS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROLE SEO BY
BUILDINGS C
CONTRACTOR -��yJ / 1� BK r
ADDRESS (r V CONNECTION DATA
CITY TEL. NO.1AX-7 15614-0 TION DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO. COUNTY L OWER
NO. DESCRIPTION OF WOR FEE TYPE F TANECTION .L. ENGTM FRO
NO OUSE SEWER CONNECTING TO D M.L.TO P.L. }
PU BLIC SEWER 0 $5.00 y
SEPTIC 1 SEEPAGE PIT OR P.C.NO.
EPO
PITS AND/OR DRAINFIELO 8-10._001 CO.IMP.READ_ JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT N� u
PRIVATE DISPOSAL SYSTEM ® $3.00 yd
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I IM9M&Nr RECORD. INSTR.NO. DATE O
WORK TO HOUSE SEWER ® $3.00 IJ
OVERFLOW SEEPAGE PIT.GRAINFIELD W
EXTN..CESSPOOL.DRYWELL.MANH O LE® S5.00 CL
ALTER.REPAIROR ABANDON HOUSE HWY.OR ST.WIDENING y
SE WER OR DISPOS AL 9 YSTEM ® 53,00
I STFRR
IN
W } I P' A.OWNERS PERMIT S 2 00 ' '° cHA DAUTHORIZATION TOTAL FEE C° FEEI HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED CON- RE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTORS SIGNA URE
SIGNED THIS DAY OF 19_ I ,{
OWNER OR NEW HOUSE SEWER / 'J �'
OWNERS AGENT CONNECT AG
ITIONAL I /�
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DNA NFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS, CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REDUIRED BY LOS ANGLES COUNTY AN STATE OF SEWAGE DISPOSAL SYSTEM
CALIFONNTA-(SRT W�"-.'-R-GG IDISiND_TGr..-
RESIDE IN, THE ASO V E ED E I NT R RTT. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE_ SEEP.PIT(B) ❑ CESSPOOLS ❑
LIGATION ROBERT WOOD
Q.cK. M.0, CASH SUPERVISING MECHANICAL ENGINEER
LAC07 1 2 7tg NOV 5 1 0 0
7.0 Or--