HomeMy Public PortalAbout5360 LOMA AVE_Sewer__ 7GA642D
6@E-663 12-34 A®P L'V A T I O WTO R' PER-MIT q• pIT 7
1
'z DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE ®ISPOSITL
Depat ent of County Engineer
County Of LOB Angeles FADDRESS
NG
WM. J. FOX, COUNTY ENGINEER CASSATT D.GRIFFIN, SUPT OF BUILDING Tr
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL ,Sr _
DESCRIPTION LOT NO„ v 0 OWNER �� y
BLOCK TRACT / ZAf MAIL
ADDRESS
NO OF BLDGS.
SIZE OF LOT NOW ON LOT CITY -_ TEL NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAPBK P
CONTRACTOR v T ( _77
ADDRESS CONNECTION DATA
HCl � S TEL. NO. _ STATION 0,,14 73 y DEPTH /
� ❑ STATE l�Ll��'� MA REFERENCE
r REGISTRATION N0. UPPERLOWER�j�l"l' ❑ COUNTY ! /J
TYPE OF CONNECTION LENGTH FROM
NO. DESCRIPTION OF WORK FEE Y CURB' P,,L. M L TO P L.
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q S 3 50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 Do-
CONNECT _ ,�r
ADDITIONAL BLDG OR 1
ORK 70 HOUSE SEWER 1 00 LCO. IMP NO. 7 ;7JOB NO
W =
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 100 TRUNK PERMIT NO. ROAD PERMIT NO -
_
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO,
SEPTIC TANK, SEEPAGE PIT OR
PITSAND/OR DRAINFIELD 2 00 INDUSTRIAL' '
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
OWNER'S PERM I 00
AUTHORIZATION TOTAL FEE it REIMBURSEMENT FEE
I HAVE DATETRACTORT TO CONNE TO THE ABODVEWITH DESCR BED EXIISTINGTHE HEREINA DWELLING APPROVALS DATE INSECTOR'S SIGNATURE
TO THE PUBLIC SEWER _
NEW HOUSE SEWER
SIGNED THIS DAY OF 19-
OWNER OR /�• CONNECT ADDITIONAL
OWNERS AGENT �t A BUILDING OR WORK
ADDRESS SEPTIC TANK, SEEP, PIT($)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL Cl DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS To ALTER, REPAIR,'SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER -
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS[ISEEP.PITS) ❑ CESSPOOLS❑
SIGNATURE ,
OF PERMITTEE '
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
&8 8 5 9 u OCT 1 4 4.50
BY BY
DEPUTY DEPUTY
BY BY
1'® DEPUTY � . yam' DEPUTY