HomeMy Public PortalAbout5428 LOMA AVE_Sewer__ CE808APPLICATION FOR PER T
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISP SAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING'AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADO RESS,'
WILLIAM A. JENSEN. Sup'1 of Building
- LOCALITY
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST
LEGAL
DESCRIPTION LOT NO e OWNER -
Aa
MAIL
BLOCK - .TRACT ADDRES
NO OF BLDG S 1 - -
-SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROCES D BY
BUILDINGS BK PG
CONTRACTO ��G�� ,"'l n �.
ADDRESS ] �./ CO ECTIO DATA _
i �' STATION / DEPTH
CITY TEL NO O _
STATE MANHOLE REFERENCE PP
REGISTRATION NO COUNTY f
NO DESCRIP ON OF WORK FEE TYPE OF LENGTH FR
HOUSE SEWER CONNECTING TO Y CURB
PUBLIC SEWER @ $5 00
SEPTIC TANK,SEEPAGE PIT OR J C NO
PITS AND/OR DRAINFIELD S1000 CO IMP NO JOB NO �J
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT N J(
'PRIVATE DISPOSAL SYSTEM @ $300 C/
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN,CESSPOOL DRYWELL MANHOLE @ $500
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s 2 Oo
CONNECTION CHARGE FEE '
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE ^ t
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING -
TO THE PUBLIC SEWER APPROVALS DA�E INSPECTOR'SSIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER 14
OWNERS AGENT / -
/ BUILDING OR WORK
CONNECT ADDITIONAL
ADDRESS
SEPTIC TANK SEEP,PIT(S)
I HEREBY AC N LEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD '
AND STATE THA HE ABOVE IS CORRECT AND AGREE TO COMPLY If
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ '
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR 7
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR'THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND {
RESIDE IN THE A VE DESI-RIBED RESI NTIA PROPERTY J J
ABANDON HOUSE SEWER +I I
SIGNATURE BACKFILL SEPTIC TANKS ❑ }(
OF PERMITTE SEEP PIT(S) ❑ CESSPOOLS A❑ y
VALIDATION R013ERT IA. WOOD
M CASH
SUPERVISING MECHANICAL ENGINEER
CK O
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