HomeMy Public PortalAbout5521 LOMA AVE_Sewer__ 76A642D ® qp�_ mn� ys�og 6yo�� PERMIT�ppp��� 1
CES08 8.88 AP LICA 11 �ON, FOR Y EB 09i'/IIIT
COUNTY OF LOS ANGELES SEWER—SEWAGE ®1SPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. I.AMBIE, County Eng�ae6r
CASSATT D. GRIFFIN, Supt of Building LOCALITY Tem le Cit
NEAREST
FOR APPLICANT T CROSS ST.
LEGAL _
DESCRIPTION LOT OWNER June M• Curly
BLOCK TRACT
U 9149
l 4 9 roadway
?� ADDSS J
NO OF BLDGS. Temp-
SIZE OF LOT NOW ON LOT CITY TEL. NO
USOF UwWmw
BUE DINGS Res. DISTRICT N0.I GROUP IK•ZMAP PROCE D,BY
T p T7f BO
CONTRACTOR L. D. Sc M. Constr. o. Q
ADDRESS 5136 No . -be e cke r - "TION DATA_
CIT;Bal IwIn Park TEL.N0. ED 8-302# STATION -JLC O DEPTH
113613 STATE MANHOLE REFERENCE
REGISTRATION NO. COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 c TYPE OF CONNECTION LENGTH FROM ,�f
SEPTIC TANK,SEEPAGE PIT OR CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
i
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TOP.6.NO.
PRIVATE DISPOSAL SYSTEM @ $1 00 0' _
CONNECT ADDITIONAL BLDG OR TRUNK PERT NO. ROAD PERMI
WORK TO HOUSE SEWER @ $1 00
ALTER, REPDISPOSALSYSIR OR TEM ON HOUSE @ $1 OO STATE ENCROACH
PERMIT NO
INDUSTRIAL
WASTE APPROV
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE d"a REIMBURSEMENT FEE
I HAVE AT DATE A CONTRACT WITH THECON-
TRACTOR TO CONNECT T THE ABOVE DESCRIBEDEXIISTItNGAMED DWELLIING APPROVALSDATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. �^ /�y�� /j
SIGNED THIS—DAY OF 19_ NEW HOUSE SEWER /j ��I 1'J�1"L�li" pl"q
OWNER OR
OWNERS AGENT— NEW CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD _
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRY-WELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING pLTER,'REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1ICHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LENSED AS REQUIRED BY LOS A LES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM TH L AL OWNER OF THE A OVE
DESCRIBED RESIDENTIAL, ROPE Y. BACKFILL SEPTIC TANKS ❑
SIGNATURE
SEEP PIT(S) ❑ CESSPOOLS ❑
OF PERMITTEE
Op VALIDATION ROBERT A. WOOD
cs� N.o. CASH SUPERVISING MECHANICAL ENGINEER
(j,1 p
L5 2 40 21 i:U(: 0 D 5 .(C I.J K
! V6 INSERTS
CEe 8 660 ^ ,
76A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A LAMBIE, County Engineer
WILLIAM A. JENSEN, Supt of Building LOCALITY '
NEAREST FOR APPLICANT TO IN ceoss sr.
LEGAL Z OWNER /
DESCRIPTION LOT N0.
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL-NO
USE DDISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS ` I BK P/ /• I
CONTRACTOR
fA D D R E S CONNECTION ATA
CITY EL.NO. STATION 4 DEPTH
STATE MANHOLE REFEREN E
REGISTRATION NO ` (� COUNTY -:7 "LOWER
NO DESCRIPT10N OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $ 00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $ 00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN CESSPOOL DRYWELL @ S 00
HOUSE SEWER CONNECTING TO P.C
PRIVATE DISPOSAL SYSTEM @ $ 00 CO IMP N0. N0.
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT N0. ROAD PERMIT NO. V
WORK TO HOUSE SEWER @ $ 00
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHcd
SEWER OR DISPOSAL SYSTEM @ $ DO PERMIT NO O
n INDUSTRIA - P4
WASTE APP OVAL W
CHARGES
OWNER'S PERMIT S 1 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
HAVE AT DATE A CONTRACT WITH THE CON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXIISTIJNGAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS 19_ NEW HOUSE SEWER
CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK.
ADDRESS SEPTIC TANK,SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY CKNOWLEDGE THAT 1 AVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ -
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR -
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 DISCONNECT PLUG AND
HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON DISCONNECT
HOUSE D
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF TH ABOVE
DESCRIBED RESIDEN L PROPE Y. BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP. PIT(S) ❑ CESSPOOLS ❑ _
OF PER MITTE
OF VALIDATIO ROBERT A. WOOD
CK. M.0. CASH SUPERVISING MECHANICAL ENGINEER -
LAP,o3 2 3 3AUG 20 1 0 D 5.00^'