HomeMy Public PortalAbout5328 LOMA AVE_Sewer__ DEPARTMENT OF COUNTY ENGDMM SEVER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
:. COUNTY OF LOS ANGELES BUILDING
WILLIAM J. FOX, COUNTY ENGINEER I ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING ^ NEAREST �J
ADDRESS �} Z /1I d 11'1/( V`� i CROSS ST.
DISTRICT NO. SER AL NO. PERMIT NO.
LOCALITY �.� �.�+�J S_ I �{J ��`�X�-
NEAREST ST.ST h' l ,t RECEIVED Y Ready for Inspection DA�i SUED
CI J / C �,�jn�
OWNERMAIL
A �,�� � ®Y6� ��.< USE ZONE OCCUPANCY r MAP
ADDRESS PG
/ K
CITY �e ��• TELNO.
CONTRACTOR /
CO.IMP.N0.
ADDRESS t JOB NO. —^
CITY TEL.NO. _TRUNK PERMIT NO.
STATE
REGISTRATION NO. ® COUNTY `
ROAD`PERMIT N0.
LEGAL STATES NCROACHMENT
DESCRIPTION LOT N0., (9'L.�. Q�� PERMIT�NO. ----------
BLOCK TRACT,"-, 7 9 INDUSTRIEAL
NO 00 WASTE APPROVAL
SIZE OF LOT ` G/ NOW ON LOTS CHARGES '
USE OF ��, I I ��Q \
BUILDINGS S� �j'- CONNECTION CHARGE FEE '
NO. DESCRIPTION OF W014K FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $ v3.50 RECEIPT NO. I o DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00' `
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00I
ALTER OR REPAIR EXISTING NO I DATE I BY
_SEWER OR DISPOSAL SYSTEM 1.00
-DISCONNECT AND ABANDON SEWER _
AND/OR DISPOSAL SYSTEM 1.00 /I CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR STATION 4— DEPTH /
PITS AND/ORDRAINFIELD 2.00 -
CESSPOOL—DRYW ELL'
SPECIAL CONDITIONS ONLY 2.00 /6-1 �6 %NUPPER EFERENCE L@>AR
TYPE OF CONNE�ON4 LENGTH FROM
OWNERS PERMIT # I oo CURB v M.L.TO P.L. •C
AUTHORIZATION TOTAL FEE �D
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING -APPROVALS INSPECT R'S_SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS___.. ....DAY OF...... ww_�__• 19NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
BUILDING OR WORK
OWNERS AGENT ..... ..... ......
SEPTIC TANK,SEEP.PIT(S)
ADDRESS . �' �r."L._£%_A_wl .�--�..tC, AND/OR DRAINFIELD
i
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL 0 DRYWELL E]CATIONAND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER, REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE S EWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS 0
SEEP.PIT(S)[] CESSPOOLS
SIGNATURE q _
OF PERMITTEE-`!'-_Y'!�-"� - -�_''
76A642A 663 7/53 (/