HomeMy Public PortalAbout5346 LOMA AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
' COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING
ADDRESS
FOR APPLICANT T FILL IN LocaLlTr
BUILDING NEAREST!}
ADDRESS CROSS ST. t
LOCALITY DISTRICT NO SERIAL NO. PERMIT NO.
A �9D93 S
NEAREST O
CROSS ST. RECEIVED BY Reedy for Inspection DATE ISSUED
OWNER
MAIL
ADDRCSS USE ZONE OCCUPANCY BK MAP PG
CITY TEL 0 R -1 I J r
CONTRACTOR _ t _ CO.IMP.NO. /J
ADDRESS,�q_,6`VV ' JOB.N0.
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TEL.NO TRUNK PERMIT N0.
STATE p� � �
REGISTRATION NO. �/� / V COUNTY ROAD PERMIT NO. /A `71' �1--
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO. - PERMIT NO.
BLOCK TRACTzzINDUSTRIAL
WASTE APPROVAL
SIZE OF LOT 5WA� NOW ON LOTS CHARGES
USE OF �—
BUILDINGS CONNECTION CHARGE FEE Q ,
NO. DESCPN3 ION OF WORK FEE REIMBURSEMENT FEE- t�
HOUSE SEWER CONNECTING TO
PUBLICSEWER @ $ 3.50 RECEIPT NO. I j,�-D�ATEI BY
HOUSE SEWER CONNECTING TO /
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR 6E•XCEPTION RECORDED
WORK TO HOUSE SEWER 1.00 NO `
ALTER OR REPAIR EXISTING I DATE �I`B`
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 -STATION _3'} �, �� DEPTH d
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2009 MANHOLE REFERENCE
gP_P.ER A10,'��LOWER
CURB/
TYPE OF,CMNECTIONP'L: LENGTH FROM N( 1e l
OWNERS PERMIT $ 1 1 ' 00 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'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS.......__-_._-DAY OF...__. _.—_19____- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT.................................... BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS...............-......—______--------------•--....................-......___ AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL[:] DRYWELL
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 CALIFO AOR THA I AM THE LEGAL OWN•
ER OF THE ABOVE D99 IBED R ENTIAL PROPER Y. BACKFILL SEPTIC TANKS
SIGNATURE SEEP.PIT(S)E] CESSPOOLS❑
OF PERMITTEEj!;.
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76A642A 663 7/53