HomeMy Public PortalAbout5527 LOMA AVE_Sewer__ 1.
78A8420-- - - APPLICATION FOR,e 9 Y15sB 4 7 '
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COUNTY OF LOS ANGELES �����=�� ��� �'��0 A
DEPARTMENT OF COUNTY ENGINEER-
'IS'
AND SAFETY DIVISION Bu1Lo1Nc 777:-'.
JOHN A: LAMBIE, County EngineerTeCASSATT D. GRIFFIN, Supt of Building LOCALITY.NEAREST•FOR ;APPLICANT TO' FILL IIVCROSS ST.LEGAi
'DESCRIPTION` LOT NO.- OWNERJ'ble'' lUl a (;t�rlyMAILJ `' aBLOCK- TRACT ADDRESS )lY9 Ea B,Yro awaNO.OF
SIZEOF LOT ' NOW.ON LOTS CirY`I'2It1pl E: Q ty°TEL..No.= A37- -
USE OFLDINGS es DISTRICT NO.I GROUP MAP ' _.PROCESS BY
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CONTRACTOR Z• D e & 1`�a V OT1StY'• CO r 421, t
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ADDRESS •O No. e,eC 'er - - CONNECTION DATA.,
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CITY ..- VV' C- - TEL.N0. - STATION S DEPTH -
STATE. MANHOLE'REFERENCE PER
REGISTRATION NO. 113613 '` ❑ COUNTY �<
NO. I DESCRIPTION OF WORK- FEE
.HOUSE'.SEWER CONNECTING TO - - -
PUBLIC SEWER - @ $3.00 TYPE OF CONNECTION LENGTHFROM.
SEPTIC TANK,SEEPAGE PIT OR - - RB P.L. •M.L.TO P.L. '—�
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW,SEEPAGE PIT,-DRAINFIELD
EXTN._CESSPOOL.DRYWELL -@ $2.00 - .
HOUSE SEWER CONNECTING TO _ - P.C:NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 . C9'4M•F.NO.
CONNECT ADDITIONAL BLDG.OR. TRUNK PERMIT NO. -ROAD PERMIT NO.
WORK TO.HOUSE SEWER @ $1.00
.ALTER,REPAIR OR ABANDON HOUSE STATE ENC NT
SEWER OR DISPOSAL SYSTEM @_$1.00 PERMIT NO, -
- - INDUSTRIAL
WASTE'APPRO -
- CHARGES-
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL.FEE 7 REIMBURSEMENT FEE
1 HAVE AT THIS DATE CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED.EXISTING>DWELLING APPROVALS - - .DATE:','. INSPECTOR'S SIGNATURE
TO THE"PUBLIC SEWER..
SIGNED THIS DAY OF ,. 19 NEW HOUSE SEWER . of
OWNER.OR - CONNECT ADDITIONAL -
OWNERS•AGENT— NEL -- BUILDING OR WORK
SEPTIC TANK,.SEEP;PIT(S) -
ADDRESS_' - AND/OR.DRAINFIELD -
I'HEREBY* ACKNOWLEDGE. THAT' I HAVE READ THIS APPLICATION
AND STATE THAT THE ABO VE IS,CORRECT AND AGREE -TO COMPLY CESSPOOL ❑ DRYWELL ❑ -
WITH ALL COUNTY ORDINANCES 'A'ND STATE LAWS' REGULATING ALTER;:REPAIR,-SEWER OR-
SEWAGE DISPOSAL SYSTEM -
I- 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 I AM.THE LEGAL OWNER OF THEABOVE.
,DESCRIBED•�RESIDENT PROPERTY BACKFILL SEPTIC TANKS El -
SEEP. PIT(S) CESSPOOLS-[:] '
SIGNATURE
OF PERMITTEE
®" V LIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL,ENGINEER.
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