HomeMy Public PortalAbout4978 LOMA AVE_Sewer__ 76A 6,/S21EI-CIE808 A-7/76 APPLICATI FOR PE`R'MIT
SEWER—SEWAGE DISPOSAL.
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
BUILDING
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LEGA TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT O. 0
a �/� AFFIDAVIT WAIVER EASEMENT RECORD,INSTR,NO, DATE
BLOCK TRACT
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT HWY. OR.ST.WIDENING
USE OF STATE ENCROACHMENT
BUILDINGS PERMIT NO.
INDUSTRIAL
CONTRACTOR WASTE APPROVAL �.
ADDRESS CHARGES 0'
CONNECTION CHARGE FEE 0
CITY TEL. NO.
STATE LIC REIMBURSEMENT FEE _
LIC E N 5E NO. CLASS
NO. 1 DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ U f
SEPTIC DANK,SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING.TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM SEPTIC TANK.SEEP,PIT(S)
CONNECT ADDITIONAL BLDG.OR AND/OR DRAINFIELD
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL q DR-YWELL ❑
EXTN..CESSPOOL.DRYWELL.MANHOLE
ALTER.REPAIR OR ABANDON HOUSE ALTER,REPAIR.SEWER OR
SEWER OR DISPOSAL SYSTEM @ SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S) [ICESSPOOLS ❑ '
OWNER'S Issuance Fee $
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AUTHOFUZATIONI TOTAL FEE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- PLUMBING AND SEWERS.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING HEREBY CERTIFY THAT1 AM PROPERLY REGISTERED AND/OR
TO THE PUBLIC SEWER. LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF
SIGNED THIS DAY OF 18„ CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO
OWNER OR RESIDE IN, THE ABO ESCRIBEO RESIIJ Et�TI L PROP RTY.
/6WNERS AGENT f/
SIGNATURE
OF PERMITTEE
VALIDATIO
CK. M,O. CASH
76A 642D-CE�808 A-7/76 APPLICATION FOR PERMIT
SEWER-SEWAGE DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
DISTRICT N0. PRO SED BY
FOR APPLICANT TO FILL IN BKGROUP MAP PG
BUILDING '
ADDRESS IH79 L A.4 &e.
LOCALITY ! e CONNECTION DAT
NEAREST STATION DEPTH
CROSS ST.
/�/p� �/ r^' `• UPPER
MANHOLE REFERENCE
!'� R V IIV ` • �V �t./ LOWER
OWNER
TYPE OF CONNECTION LENGTH FROM
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P.C.NO.
CITY c E
04e 'TL. NO. 87. 7 5.3 CO.IMP.NO. JOB NO.
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LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
S� — )� ^� A AFFIDAVIT WAIVE. EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT / -
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF ��/^ STATE ENCROACHMENT
BUILDINGS ` /f �/ Ij� PERMIT NO.
CONTRACTOR /v/VADC—Al 8L!/�1711611 ePAS/ 6sEJ INDUSTRIAL
WASTE APPROVAL
ADDRESS . CJ /Q-Tb'f �jl�[1 CHARGES C)
CITY CONNECTION CHARGE FEE
STATELIC v REIMBURSEMENT FEE
LICENSE NO: CLASS
NO. 1 DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER
SEPTIC LANK.SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR DRAINFIELD @ CONNECT ADDITIONAL �o
HOUSE SEWER CONNECTING TO
BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM @ SEPTIC TANK,SEEP,PIT(S)
CONNECT ADDITIONAL BLDG.OR AND/OR DRAINFIELD
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL ❑ DRYWELL ❑
EXTN..CESSPOOL.DRYWELL.MANHOLE
ALTER,REPAIR OR ABANDON HOUSE ALTER,REPAIR.SEWER OR
SEWER OR DISPOSAL SYSTEM Q SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
v ABANDON HOUSESEWER
1 6. BACKFILL SEPTIC TANKS ❑
SEEP.PITS) ❑ CESSPOOLS L
A
OWNER'S Issuance Fee $
AUTHORIZATION TOTAL FEE /il HEREBY ACKNOWLEDGE THAT I HAVE RE7m]AP
v AND STATE THAT THE ABOVE IS CORRECT ANE T
WITH ALL COUNTY ORDINANCES AND STATRE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON PLUMBING AND SEWERS.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER 1 HEREBY CERTIFY THATI AM PROPERLY,REGISTERED�7 LICENSED AS REOUIRED BY LOS ANGLES COU Y AND FSIGNED THIS� L1L DAY OF I9�( CALIFORNIA OR THAT I A THE LEGAL OW O . AND I
OWNER OR �. RESIDE IN, THE AB VE E C BED SID T A PROPE
1OWNERS AGENT /� SIGNATURE
/!`'LA OF PERMTTTE
I�Y, VALIDATI \\\
(( �� CK. M.O. CASH
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