HomeMy Public PortalAbout5719 LOMA AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER 'SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING. "' {`
ADDRESS S Z /s q AJ. L Q ,7-a.
FOR APPLICANT TO FILL IN LOCALITY ,
BUILDING �'.s� / O NEAREST ^
A[?DRESS !„G/ MA CROSS ST. te $�, �lJ in -L—S
LOCALITY DIST I T NO. SERIAL NO. PERMIT NO... c
NEAREST L9 _ "jam A I I J
CROSS ST, y�/j• / RECt 1VE'D^BY Ready for InspectiongDATE ISSUED
OWNER S
MAIL
ADDRESS (J /i< .l�y C�/r i UiSEZQNE (OCCUPANCY, BK MAP PG
CITY; TEL.NO.�r�1�# /YS L
CONTRACTOR. - ' ` 3 7 Z —2 %1 FJ
ADDRESS ` JOB NO.
CITY AzzTEL.N0. 0_P g,p L�4V 0 TRUNK PERMIT NO.'
_ / 7%®�2p COUNTY. ROAD PERMIT NO.
REGISTRATION NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO. J PERMIT NO.
BLOCK TRACT. / 7-7INDUSTRIAL
4::-
WASTE APPROVAL
SIIE'OF LOTWON LOTS
5�+ CHARGES
USE j1
BUILDINGS/F/ CONNE 'N;N CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO a REIMBURSEMENT FEE /
PUBLIC SEWER @ $ 3.50 3 S{' RECEIPT N0. DATE' I BY
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR _SEX PTION RECORDED
WORK TO"HOUSE'SEWER 1.00
ALTER OR REPAIR EXISTING NO' I DATE_ BY
'SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
.AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
,SEPTIC TANK,SEEPAGE PIT OR STATION V -1. 5 r
PITS AND/OR DRAINFIELD 2.00 DEPTH
CESSPOOL—DRYW LL
- SPECIAL CONDITIONS ONLY 2.00 - l"/, I/\ I_ MAN�H .REFERENCE LOWER
_ 7 (TYPE OF CCONNECTI LENGTH FROM 12
OWNERS . PERMIT ; 1 00- Y. CURB P.L. M.L.TO P.L.
AUTHORIZATION TOTAL FEE
HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
HAVE
TO CONNECT THE ABOVE DESCRIBED EXISTING. APPROVALS INSPEC ,O R'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER /
SIGNED THIS--.... OF---
OWNER
sol NEW HOUSE SEWER C
-•--•----DAY OF--- --._......�-�-------.. 19.----,
OWNER OR /J/$ a� CONNECT ADDITIONAL
OWNERS AGENT.. _ BUILDING OR WORK
--- - -
ADDRESS..._.-..._............................ SEPTIC TANK,SEEP.PIT(S)
-------- -------- ------...... AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL DRYWELL �—
CATION:-A-ND STATTHAT THE ABOVE IS CORRECT AND AGREE
=,TO COMPLY-.WE ITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1-THEREBY CERTIFY THAT I AM' PROPERLY REGISTERED DISCONNECT PLUG AND
ND/OR' LICENSED AS REQUIRE
D 'BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
"AAND-STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN.
-.ER.4OF THE ABOVE DE CRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE � f� SEEP.PIT(S)E] CESSPOOLS E
OF PERMITTEE..._ e ...
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