HomeMy Public PortalAbout5505 LOMA AVE_Sewer__ � r
76A64 3-E4 APPLICATION FOR PERMIT
76A642D
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING /
JOHN A. LAMBIE, County Engineer ADDRESS 40 /J�. �i f /C
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST ' e
LEGAL "D�,, /f�fy /�i �` �R d N�-v ¢�J I
DESCRIPTION LOT NO OWNER
BLOCK TRACT MAIL
yADDRESS
NO SIZE OF LOT Y NOW OON LOTS / 7 M TEL NO�//
CITY
USE OF ds DISTRICT NO GROUP MAP PROCES D BY
BUILDINGS
n yy, /� y K P G
CONTRACTOR 6(„s r/5 �/ /�/ 1/ A/1 V� � 0 � '•�
ADDRESS 'a4- "--o Aa r/ / CONNECTION DATA
CITY TEL NO Iy � B ! STATIONJA' DEPTH
/► /I�� MANHOLE REFERENCE UPPER
REGISTRATION NO P � , >Sn {`) COUNTY LOWER
NO GESCRIPTI N OF WORK FEE TYPE OF CONNECTION LENGTH FROM
OUSE SEWER CONNECTING TO Y CURB P L ML TOPIL
PUBLIC SEWER ® SS 00 P C NO
SEPTIC TANK,SEEPAGE PIT OR CO IMP NO JOB NO 0-
PITS AND/OR DRAINFIELD @ E10 00 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO U
PRIVATE DISPOSAL SYSTEM $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER I EASEMENT RECORD INSTR NO DATEa
WORK TO HOUSE SEWER $300 O
OVERFLOW SEEPAGE PIT.DRAINFIELD
E%TN CESSPOOL,DRYWELL,MANHOLE @ $500 U
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING 0-
a
SEWER OR DISPOSAL SYSTEM A@ $300 STATE ENCROACHMENT - N
PERMIT NO Z
INDUSTR3A
j A e
CHARGES
OWNERS PERMIT $ z 00
AUTHORIZATION TOTAL FEE ONNECTI ON CHARG
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON• REIMBURSEMENT FE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER / DATE I NSPECTgb SIGNATURE
SIGNED THIS DAY OF
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS 47 BUILDING OR WORK
SEPTIC TANK SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD ,
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
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 ABO V DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTE EEP,PITS) ❑ CESSPOOLS ❑
VALIDATIOI;I---) ROBERT WOOD
CK M oCASH SUPERVISING MECHANICAL ENGINEER
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LAW� a.� AUG 2 5 n 7.a Q- CC