HomeMy Public PortalAbout5340 LOMA AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES gU1LD1NG
WILLIAM J. FOX, COUNTY ENGINEER I ADDRESS � ���(f��
FOR APPLICANT TO FILL IN LOCALITY
BUILDING NEAREST
ADDRESS CROSS ST. �m
LOCALITY ®` �� jyry, � DISTRICT NO. SERIAL NO. PERMIT NO.
A, �.--> S
NEAREST
CROSS ST. SIVE,5BY,_'� Ready for Inspection UVATE ISSUE�D�
OWNER .-11
ADDRESS �eJA � C„MAILUSE`ZONE" OCCUPANCY BK MAP PG
CITY TEL.NO.
r
CONTRACTOR y'' CO.IMP.N0.
ADDRESS
JOB N0.
CITY EL. TRUNK PERMIT NO.
.f] STATE
REGISTRATION NO. COUNTY ROAD PERMIT NO. 2 74—/
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO � PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT / N0.OF BL +1
NOW ON LOT HARGE
! C
USE OF
BUILDINGS- CONNECTION CHARGE E
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $ 3.50 RECEIPT N0. ATE I BY
. HOUSE SEWER CONNECTING TO
--PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION REC DED
WORK TO HOUSE SEWER 1.00
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 a CONNECTION DATA
—SEPTIC TANK,SEEPAGE PIT OR e®�v,
PITS AND/OR DRAINFIELD 2.00 STATION �"�-,b DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLEU �REFERENCE LOWER
TYPE OF iFN CT 10 LENGTH FROM
OWNERS PERMIT $ 1 00 CU B M.L.TO P.L.
AUTHORIZATION I TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR' SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS...... -_-_-DAY OF------'��?�1�....-................ NEW HOUSE SEWER
OWNER OR /�� y�, / _ CONNECT ADDITIONAL
OWNERS AGENT.. lk.c;r�'=-V- 1 '✓l __._._......... _ BUILDING OR WORK
�� � �41A�„rti SEPTIC TANK,SEEP.PITS)
ADDRESS.......................:................,�_-_-- --.. -------...__..- AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL I] DRYWELL C]
CATION AND 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 SEWER
AND STATE OF CALIFORNIA OR THAT I AM HE LEGAL WN-
ER OF-THE ABOVE DESCRIBED RESID L PROPE)iT BACKFILL SEPTIC TANKS[
SIGNATURE SEEP.PIT(S)E] CESSPOOLS F]
OF PERMITTEE----- - - - - -
76A642A 663 7/53