HomeMy Public PortalAbout5417 LOMA AVE_Sewer__ DEPARTWOff OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITYBUILD
NG NEAREST
ADDRESS ICROSS ST. / "C
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST A17 4
CROSS ST.
REC&IVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL USE ZONE OCCUPANCY MAP
ADDRESS BK PG
CITY TEL.NO. .i ,�' //%f�i� • I `a'��
CONTRACTOR
Co.IMP.N0.
l � p
ADDRESS � JOB.N0.
CITY Az
�,,��LTEL.NO. /lP TRUNK PERMIT 140.
p STATE
REGISTRATION N0. /i G��_. [14A�'COUNTY ROAD PERMIT 140.
LEGAL STATE ENCROACHMENT
DESCR.PTION LOT NO. " PERMIT NO.
BLOCK TRACT �® WASTE APPROVAL
SIZE OF LOT �� NO.OF BLD
NOW ON LOTS lid CHARGES
USE OF
BUILDINGS CONNECTION CHARGE E
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLICSEWER @ $ 3.503) RECEIPT NO. I DAT I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPT N R ORDED
WORK TO HOUSE SEWER I.00 NO
ALTER OR REPAIR EXISTING DATE I BY
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 DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 I ��® A HOLE-REFERENCE
e
TYPE OF CONNECTION LENGTH FROM �J��
Y. , B P.L. M.L.TO P:L.
OWNERS PERMIT $ I 1 c�
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 THEA PUBLIC SEWER P
4 y � � 19Q-/ NEW HOUSE SEWER 9 ��
SIGNED THIS----.....--••----- AY OF.-------=------�=--------••------ -
.1 1 CONNECT ADDITIONAL
OWNER OR J�, f J� � BUILDING OR WORK
OWNERS AGENT�--�.&Ie.--(!4- y _.....•-'---....-.........v. - SEPTIC TANK,SEEP.PIT(S)
ADDRESS.-........-..._------•-•-•---_---------------•-• ......_ AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL❑ DRYWELL ElCATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO CO RS PLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL-SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
S
SIGNATURE
ABOVEER OF THE ESCR ry BED RESIDENTIAL PROPERTY. SEEP.PIT(S)EBACKFILL TIC TANKS
CESSPOOLS❑E]
OF PERMITTEE--- ��� - - ..........................
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