HomeMy Public PortalAbout5622 LOMA AVE_Sewer__ V,, ..
6A642D IA,0.62
7APPLICATION FOR PERMIT
8A84
COUNTY OF LOS ANGELES SEWER SEWAGE DIS''POSAL,
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS !�
WILLIAM A. JENSEN, Supt of Bt
- - LOCALITY
Q' - NEAREST /
FOR APPLICANT TO FIcRD55 ST.
DESCRIPTION'
LOT NO. OWNER
MAIL .
'BLOCK TRACT ADDRESS
NO. OF SLOGS. _
SIZE OF LOT _N'OW ON LOTCITY �". v TEL. NO. '
,USE OF - - - -
BUILDINGS �,, Q/� ) DISTRICT NO. GROUP Az SK
PG PROCESSED BY
'CONTRACTOR — R _ ✓/_ — _ �f V-� /`� /,�,_ J\
ADDRESS ,i 2l �. CONNECTION DATA -
1 i
ST TION DEPTH
CITY � TEL. NO. �r �/ -
'f MANHOLE � 'EREGTE-
STATE r UPPER
REGISTRATION NO. I COUNTY LOWER
_ a.
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH,FROM O
HOUSE SEWER CONNECTING TO - Y. CURB P.L. M.L.TO P.L. U
PUBLIC SEWER @' '$5.00 P.C.NO. d/
SEPTIC TANK,SEEPAGE PIT OR CO-.IMP.NO. JOB NO. 3 O
PITS AND/OR DRAINFIELD @ $10.00 -
HOUSE SEWER CONNECTING TO TRUNK'PERMIT NO. - ROAD PERMIT NO.� (J
PRIVATE DISPOSAL SYSTEM @ $3.00 W
CONNECT ADDITION A L BLDG.OR AFFIDAVIT .WAIVER .EASEMENT RECORD.-INSTR.NO. DATE d
WORK TO HOUSE SEWER ( $3.00 - h.
OVERFLOW SEEPAGE PIT,DRAINFIELD Z
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 - '
ALTER.REPAIR OR ABANDON HOUSE - HWY.OR ST.WIDENING Y�,,,,r•�•'
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.. !.•��~�
INDUSTRIAL -
WASTE APPROVAL.
CHARGES
OWNER'S PERMIT $ 2 00 CONNECTIO CHARGE FEE
AUTHORIZATION TOTAL FEE G
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REy. BU RSEMENT FEE' _
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING -
TO THE PUBLIC SEWER. `" - APPROVALS - - DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY�OF 9
OWNER OR - NEW HOUSESEWER
OWNERS AGENT CONNECT ADDITIONAL
` BUILDING.OR WORK IP Y&!" at''; `p•
ADDRESS ,.
- SEPTIC TANK,SEEP,PIT(S) a
I HEREBY ACKNOWLEDGE TH IHAVE R AD THIS APPLICATION A'NDVOR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY _
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING - -
PLUMGING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ -
I. HEREBY CERTIFY THAT .'AM PROPERLY ER D AND/OR ALTER,REPAIR,SEWER OR -,
LICENSED AS REQUIRE LOS ANG S UNTY AND STATE OF SEWAGE DISPOSAL SYSTEM ! A
CALIF 0RN'I"A OR THAT THE LEGA OW OF, AND INTEND DISCONNECT PLUG AND
RESIDE•'IN,'-THE`A BO ESC BED ESID NTI L'PR TY.' ABANDON HOU SE'.SEWER
s . t
SIGNATURE BACKFILLSEPTIC TANKS El ,_
OF PERMIT \. ^
SEEP,PIT(S)'-❑ CESSPOOLS ❑ - "
- - TIO - ROBERTA. WOOD. . -
r SUPERVISING MECHANICAL ENGINEER .
C �•_ M.O. CASH
T i ho 2 .2.7 1� AUG 5 1, o 0 5.4 0r 4 .