HomeMy Public PortalAbout5705 LOMA AVE_Sewer__ -1 APPLICATION,
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL i
Deportment of County Engineer
County of Los Angeles BUILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS
CASSATT-0. GRIFFIN.SUPT OF BUILDING LOCALITY
FOR- APPLICANT TO FILL IN NEARESr
CROSS ST.
LEGAL �y
DESCRIPTION LOT N0. OWNER
BLOCK- a� TRACT L? 7 '? MAIL ;,/7 e�
ADDRESS (
� /" �
`.J(^ 7� I G, NOW ON, �.�': TEL. NO.
SIZE OF.LOT CITY
USE OF
BUILDINGS ( . DISTRICT N GROUP MAP
BK PG
CONTRACTOR a.�..-.�^-� - - ' +-
ADDRESS 4;;9 A' J am` / / .. ••• /
CONNECTION DATA
CITY "TEL. NO. �` T �4 DEPTH
❑ STATE / p� MA REFERENCE
REGISTRATION NO. al [3COUNTY .OM:4 PPF imam_
+ — TYPE NECTION LENGTH FROM S
NO. DESCRIPTION OF WORK FEE Y• CURB P.L. M.L. TO P.L.
HOUSE SEWER CONNECTING TO �-ry—
PUBLIC SEWER- t"a $ .,3:50
HOUSE
HOUSE SEINER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 -
COADDITIONAL BLDG, OR - CO. IMP. N0. L �Jp6. N0.
WORKRK TO O HOUSE SEWER 1.00 cJ
ALTER OR REPAIR EXISTING �/� -
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT'NO. ROAD PERMIT N0. (e
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
ANDi OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
__PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY .2.00 CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT $ 1 00
AUTHORIZATION. TOTAL FEE REIMBURSEMENT FEF.
TRACTORHAVE T TOS CONNECT THE DATE ABODVEyVDESCR BED EXISTINGITH THE HEREIN A DWELLING APPROVALS DATE I INSPECTORS SIGNATURE
TO THE PUBLIC SEWER
OF — 19
SIGNED THIS DAY NEW HOUSE SEWER
OWNER ORmac. CONNECT ADDITIONAL
OWNERS AGENT � ""' "' ��✓ -'( �4�"` BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S).
ADDRESS- AND/OR DRAINFIELD
!;HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR,
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 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 1 AM THE LEGAL OWNER OF THE ABOVE _
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑'
SEEP.PIT(5) ❑ CESSPOOLS 0.
- SIGNATURE
OF PERMITTEE -
Y
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
',BY 'hU58Y5 .4�- JUL 1"� 4 4.5'
DEPUTY �" DEPUTY
`j BY - - - BY - WIEPUTYDEPUTY _