HomeMy Public PortalAbout5339 LOMA AVE_Sewer__ SINN-e6s s-as APPLICATION FOR PERMIT
IN
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deportment of County Engineer ��� 39 ����
County Of LOS Angeles BUILDING
'WM.J. FOX, COUNTY ENGINEER _ADDRESS
CASSATT D.GRIFFIN, SUP'T OF BUILDING LOCALITY rL�&P LI. rX
FOR APPLICANT TO FILL IN CROSS ST. 6 jt
LEGAL
DESCRIPTION LOT NO. ppp �r ' OWNER ,L p 9 6,` RR j9 I
BLOCK " TRACT /"�,d' ADDRESS L�,3-7� OA%:-1
NO. OF BLDGS.
_ SIZE OF LOT NOW ON LOT CITY a . TEL. NO.'
USE OF / / /W
y'
BUILDINGS G..s, /, (/" DISTRICT NO. GROUP MAP
r/ BK PGG
CONTRACTOR I M I
ADDRESS S {�• 5- _ A -A CONNECTION DATA f
CITY - TEL. NO. A'r 776 7 q STATIONr
.�e�/��'_ DEPTH p
{1� „/®/w
[I STATE MANHOLE REFERENCE ®` 9 �✓ Fo LOWER
REGISTRATION N0. i/ [71 COUNTY if J
NO. DESCRIPTION OF WORK FEE
TYPE OF CON14ECTION LENGTH FROM
PUBLIC SEWER 3.50 O
HOUSE SEWER CONNECTING TO J 0 Y, r— P.L. M.L. TO P.L.
$ - — �
HOUSE SEWER CONNECTING TO
P RIVATE•DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR "y� P. C NO.
WORK TO HOUSE SEWER 1.00 CO. IMP. NO. / JOB NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO./0,0,,M
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- DRYW ELL
WASTE APPROVAL '
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT 5 1 00
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
1 HAVE DATEWITH THE HEREIN
TRACTORTTOS CONNECTO THE ABOVE DESCRIBED EXISTINGAMED DWELLIONG APPROVALS DATE INSP CTOR SSIGNATURE
TO THE PUBLIC SEj
SIGNED THIS r"-DAY OF 19 'NEW HOUSE SEWER S 5
NNECT ADDITIONAL
OWNER OR .JILDING OR WORK
OWNERS `AGENT �� `�
I� SEPTIC TANK, SEEP, PIT(S)
ADDRESS v sL� - AND/OR DRAINFIELD
IO ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL C3AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR, SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON'HOUSE SEWER '
DESCRIBED RESIDENTIAL PROPERTY.1 E;BACKFILL SEPTIC TANKS
SIGNATURE SEEP. PIT(S) CESSPOOLS
OF PERMITTEE _
WILLIAM J.FOX, COUNTY ENGINEER VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR
AC,0 5 9 5 0 PLAY 14 4 4.5 0 n