HomeMy Public PortalAbout6426 ENCINITA AVE_Sewer__ `a� C 0
CEBOS 3.62 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER - - - - - - - -- -- --
BUILDING AND SAFETY DIVISION auILDINc
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS 6426 Encinitas-,
COLEMAN W. JENKINS. SUPT. of BUILDING Temple City
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST. EH2O nl
LEGALy 1 Ray G. Fortner
DESCRIPTION LOT NO. OI�fjr
// �� / OWNERMA
T
BLOCK 5.�4/L{ 5 "f/L[„'-[-I--�v� �[� a ADpRE55 `�Q 51(�✓ /E[ • Las Tun
pas'
NO
SIZE OF LOT NOWOON LOTy. C V CITYTemple Vit TEL. N.. 286-3125
VBE OF
BV ILDINGS I�
DISTRICT NO.1 GROUP MAP
Wrecking
BY
CONTRACTOR Mead House recking Co �`� a //
ADDRESS 135 Na Daisy Avenue, CONNECTION DATA
CITY Pasadena TEL. NO. 796-4051 STATION DEPTH
STATE LIC MANHOLE REFERENCE UPPER
LICENSE NO. CLASS LOWER
NO. .DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L }
PV ELIC SEW ER E5.00 a
SEPTIC TANK,SEEPAGE PIT OR JOB NO. O
PITS ANO/OR DRAINFIELD f10.00 CO.IMP. NO. JOB NO. u
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO,
PRIVATE DISPOSAL SYSTEM $3.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT 1M1I. IA!I[.E.lRECORD.INBTR.NO. DATE r
WORK TO HOUSE SEWER $3.00 u
OVERFLOW SEEPAGE PIT.DRAINFIELD W
E%TN..CESSPOOL.DRYWELL.MANHOLE CD $5.00 0_
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING 'Al
SEWER OR DISPOSAL SYSTEM f3.00 STATE ENCROACHMENT
d it PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $1 z 00
AUTHORIZATION TOTAL FEE fJA[ONCONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAM ED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER . APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS JAI DAY OF F 4n OW446m, 19
OWNER OR NEW HOUBE SEWER
OWNERS 4GENT CONNECT ADDITIONAL
pORE55 BUILDING OR WORK
SEPTIC TANK,S PIT(S)
HEREBY ACNNOW LEDGE TH HAVE READ THIS APPLICATION gryD/OR GRAINFIELD
AND STATE THAT THE ABOVE CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL Cl ORYWELL Cl
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I APO THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A BOVE.IOESCRIOEO ES TI OPERTY, qBA NOON HOUSE SEWER
SIGNATURE /
OF PERMRTEE BACKF SEPTIC TANKS ❑
SEEP.PIT
(S) ❑ CESSPOOLS
VALIDATION ACK R. ALLEN
/�// SUPERVISING MECHANICAL ENGINEER
CK. M.0. CASH
I p-. 9 7 5 8 MAY 5 1 0 0
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