Loading...
HomeMy Public PortalAbout5303 LOMA AVE_Sewer__ 2/70 76A 642D APPUCATIO FOR P�fT 76A 6 COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, COUNTY ENGINEER ADDREss COLEMAN W JENKINS, SUP T OF BUILDING LOCALITY NEAREST . FOR APPLICANT TO FILL IN CROSS ST (PRINT OR TYPE ONLY) LEGAL DESCRIPTION LOT NO OWNERGRA { ``•N� MAIL BLOCKF TRACT d a ADDRESSQ NO OF BLOGSu SIZE OF LOT NOW ON LOT CITY ^� TEL NO 1 USE OF BUILDINGS joLt S:3 p + DISTRICT NO[GROUP CLASS MAP CESSED BY �q/ /B,//KA PS CONTRACTOR -5DT Sj AI - b , ADDRESS V CONNECTION((V// ATA j. CITY TEL NO STATION � /1 y DEPTH f .2- STATE l STATE LIC MANHOLE REFERENCE l! , v UPPER LICENSE NO CLASS U "gees NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGT FROM HOUSE SEWER CONNECTING TO Y 14 PL M L O P L G PUBLIC SEWER @ $S 00 PC NO SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO PITS AND/OR DRAINFIELD @ $1000 HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO d PRIVATE DISPOSAL SYSTEM @ $300 O CONNECT ADDITIONAL @�R O AFFIDAVIT w�IVE■ [AS EMf HT RECORD INSTR NO DATE U WORK TO HOUSE SEWER S300 OVERFLOW SEEPAGE PIT DRAINFIELD E XTN CESSPOOL DRYWELL MANHOLE @ $S 00 O ALTER REPAIR OR ABANDON HOUSE HWV OR ST WIDENING SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT W PERMIT NO n. INDUSTRIAL N WASTE APPROVAL Z_ OWNER'S PERMIT s o0 CHARGES CONNECTION CHARGE FEE _ AUTHORIZATION TOTAL FEE 66 0 IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR b SIGNATURE SIGNED THIS Y OF 19_ OWNER OR � NEW HOUSE SEWER OWNERS AGENT ����444fff cl z© v- �' }6A J+ Cl CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK SEEP PIT(b) I O HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION gND/ R DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND, STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR CE LINSED AS REOUIRE0 BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN THE>r DESCESC R� SIDENTIAI. PRO ABANDON HOUSE SEWER SIGNATURE OF PERMITTEE j'�[IJ BACKFILL SEPTIC TANKS ❑ ❑ SEEP PIT(S) ❑ CESSPOOLS VALIDATION JACK R. ALLEN SUPERVISING MECHANICAL ENGINEER CK M O CASH 1 2 7lZMAY 2310 D 6.0 0 ams 5-65 76A6420 APPLICATION FOR PERMIT 76A 64 COUNTY OF LOS ANGELES I SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOAN A LANIBIE County Engineer ADDRESS C1 d 0 COLEMAN W JENKINS, Sup't Of 13ulldtng LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST C LEGAL DESCRIPTION LOT NO OWNER (r MAIL BLOCK TRACT ADDRESS ivtr NO OF "LOGS SIZE OF LOT NOW ON LOT CITY TEL NO USE OF DISTRICT NOGROUP MAP PROCESSED BY BUILDINGS BK P 00, CONTRACTOR ADDRESS` 6/ VVVVVVVV CON ECTION DATA CITY / EL NO STATION DEPTH / LICEN CENSE PPER NO CLASS MANHOLE REFERENCE ' NO _ GES RI ION OF WORK FEE TYPE OF CO ION LENGTH FROM �O HOUSE SEWER CONNECTING TO Y URB P L M L TO P L PUBLIC SEWER @ $ 5 00 DTIC TANK SEEPAGE PIT OR PC NO d PITS AND/OR DRAINFIELD C $10 00 CO IMP NO JOB NO /' O HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO `y u PRIVATE DISPOSAL SYSTEM C $ 3 00 CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO ATE O WORK TO HOUSE SEWER C $ 3 00 REPAIR R ABANDON HOUSE U SEWER OR DISPOSAL SYSTFM C $ 3 00 W UHAINIIELU HWY OR ST WIDENING d E%TN ,CESSPOOL, MANHOLE C $ 5 00 h BIATEENCROACHMENT z PERCOLATION TEST C $ 5 00 PERMIT NO INDUSTRIAL WASTE APPROVAL OWNERS PERMIT $ 2 00 CHARGES AUTHORIZATION TOTilf')AL FEE OCONNECTION CHARGE FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED CON. REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLICSE [ APPROVALS DATE INSPECTC, IGNATU RE SIGNED THIS _DAY OF � 19� OWNEROR NEW HOUSE SEWER eF 6 OWNERS AGENT CONNECT ADDITIONAL ' BUILDING OR WORK ADDRESS SEPTIC TANK SEEP,PIT(S) I HEREB ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ I HEREBY 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 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PR ERTY ABANDON HOUSE SEWER SIGNATURE OF PERMITTEE BACKFILL SEPTIC TANKS 13 SEEP PIT(S) [I CESSPOOLS VALIDATIO CK M O CASH LA06 6 4 1 8Z8 DEC 19 1 0 D 7.0 0 a