HomeMy Public PortalAbout5644 LOMA AVE_Sewer__ 76A 642[)=-CE808-10-71 APPLICATION FOR PE MIT .
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING JJ 9
ADDRESS
LOCALITYG' L•'r -
NEAREST
FOR APPLICANT TO FILL IN CROSS ST..
LEGAL - // ,qq hh c _ -
DESCRIPTION LOT NO. 2_1 OWNER /�j ° /i V � ,l k
MAIL
BLOCK TRACT ADDR
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SIZE OF LOT NOW ON LOTS CITY /Z-�'J ��e C( TEL. NO. ^�
USE OF DISTRICT NO. GROUP MAP PS
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BYBUILDINGS {,/}(�,/) BK60NTRACTORjl Q 'r 'y /
ADDRESS V •••11I��� CONNECTION«t,,, ��WYYDAT
CITY TEL. NO.
STATION DEPTH
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STATE LIC �U
LICENSE NO, CLASS MANHOLE REFERENCE
NO. .DESCRIPTION OF WORK FEE TYPE OFCONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P`L. M.L.TO P.L.
PUBLIC SEWER - @ $7.00
P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD 810.00 CO. IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. d -
PRIVATE DISPOSAL SYSTEM @ S3.00 O
x.CONNECT ADDITIONAL BLDG.OR O AFFIDAVIT WAIVER.-EASEMENT RECORD.INSTR.NO. DATE V
WORK TO HOUSE SEWER. @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD of
EXTN..CESSPOOL,DRYWELL,' @ $5.00 O
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING H
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT W
MANHOLE PERMIT NO. 1y
$7.00 H
.. - INDUSTRIAL
WASTE APPROVAL Z
CHARGES
OWNERS PERMIT 8 3 00
AUTHORIZATION I TOTAL FEE 160 CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. - APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF _ 19_ .
OWNER OR NEW HOUSE SEWER -
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS
BUILDING OR WORK
SEP
PTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ANE)/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTYORDINANCES,AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL.❑ -
I 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
RES I DE IN, THE ABOVE DESCRIBE RESID/E/p�TI PROPERTY. ABANDON HOUSE SEWER
'SIGNATURE (�/ / BACKFILL SEPTIC TANKS ❑,.
OF PERMiTTE SEEP.PIT(S) ❑ SPOOLS ❑
VALIDATION cK. M,.o: CASH
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