HomeMy Public PortalAbout5317 LOMA AVE_Sewer__ D
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69 12-54 APPLICATIO17®R PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER SEWAGE DISPOSAL
Department of County Engineer
County of Los AngelesBu1LDING s
WM. J. FOX, COUNTY ENGINEER IN ADDRESS
R a
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY G
Mi-
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER �}'„/
BLOCK TRACT MAIL +� /
adi:
ADDRESS
J� NO. OF BLDGS. �C� r-
SIZE OF LOT."J_0 I.el) NOW ON LOT QC.. CITY TEL. NO.
USE OF Q� i(
BUILDINGS ./ -�t. DISTRICT GROUP MAP _
BK PG
CONTRACTOR _ . I �.
ADDRESS '� ® � CONNECTION DATA -�
STATION -'� � 3 DEPTH d
CITY TEL.. NCO.,4® � ' ® � Y-3
CI .ESE
13 "'9' EICOUT TY � MA UPPER/ FEREN CE
REGISTRATION NO. //
TYPE NIJECTIO LENGTH FROM d
No. DESCRIPTION OF WORK FEE _J.� CURB a �" M.L.
TO P.L.
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q $ 3.50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO. IMP. NO. /3477 JOB. NO.
_ 'WORK TO HOUSE SEWER 1.00 _
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.�� j���,
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO,
SEPTIC TANK,SEEPAGE PIT OR
PITS.AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT 5 1 00 -
AUTHORIZATION TOTAL FEE 44
2-0 REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED XISTING DWELLING APPROVALS DATE INSPECTVS SI aNATURE
TO THE PUBLIC SEW
SIGNED THIS AY OF 19_ 1 NEW HOUSE SEWER ® f
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS - SEPTIC TANK, SEEP, PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ TH PLICATION CESSPOOL❑ DRYWELL[3AND STATE THAT THE ABOVE IS CORRECT AND AlE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LA. REGULATING ALTER, REPAIR, SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
-
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR D
DISCONNECT PLUG AN
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEW
CALIFORNIA OR THAT. 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROP RTY. BACKFILL SEPTIC TANK
s SEEP.PIT(S) ❑ CESSPOOLS B
SIGNATURE
OF PERMITTEE
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
L.. 2 9 9 7 ZR. FEB 16 4 4.5 0
BY BY
DEPUTY DEPUTY
BY BY �
® DEPUTY DEPUTY