HomeMy Public PortalAbout5746 LOMA AVE_Sewer__ CE80B 11-57 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELESSEWER-SEWAGE.-MISPOSAL,
DEPARTMENT."OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING s „
JOHN.A.LAMBIE, County Engineer, ADORESSV
CASSATT D. GRIFFIN, Supt of Building LOCALITY
FOR APPLICANT TO FILL IN ceoss sr.
LEGAL /
DESCRIPTION LOT NO.�G SD OWNER
BLOCK TRAC �/ T .aj�- MAIL -
/2"/f, ADDRESS, � -S 1a• .'yam �..
SIZE OF LOT � NOW ON LOT - / CITY TEL NO,r•,. �~ <
USE OF
BUILDINGS •e,.- - ` -DISTRICT NOv GROUP. ` MAP
,CONTRACTOR - _- .I K I/-7
ADDRESS V� 'jl/. - 'J - CONNECTION DATA fff�
CITY, ��- / TEL.N0. STATION Z ! `„ DEPTH e'
/ STATE. MANHOLE REFERENCE - UPPER
REGISTRATION NO. COUNTY OWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO a -
PUBLIC SEWER - e°
SEPTIC TANK,SEEPAGE PIT OR TYPE 0 CON ION LENGTHTO PFROM
Y. CURBP.L. M.L. .
�j
;
PITS AND/OR DRAINFIELD - @ $3.00 � '
OVERFLOW SEEPAGE PIT,DRAINFIELD -
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $2.00 -
HOUSE SEWER CONNECTING-TOP. C.NO.
,
PRIVATE DISPOSAL SYSTEM @ $1.00 -
CO.IMP. N0. JOB N0.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @. $1.00 - TRUNK PERMIT NO. ROAD PERMIT NO. -
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $1.00 STATE ENCROACHMENT
PERMIT NO.
,INDUSTRIAL-
- WASTE APPROVAL
,�t:'- - CHARGES.
OWNER'S PERMIT g 00 CONNECTION CHARGE FEE.-
AUTHORIZATION _ _ - _ _
TOTAL FEE E REIMBURSEMENT FEE '
1 HAVE-AT-THIS DATE A CONTRACT WITH THE-HEREIN -NAMED,CON.—
TRACTOR
ON.^TRACTOR TO CONNECT THE ABOVE DESCRIBED,EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE'
TO THE PUBLIC SEWER. _ _ _ _ _ - - _ __ _ _ _ •• _ _••
SIGNED THIS A� F 19 NEW HOUSE SEWER
OWNER OR- _ ...__.�.._•�. -- _ .•» - _--"'. ."..CONNECTADDITIONAL•^ - _-•��µ-�- 1---•^u- - -
OWNERS AGENT BUILDING OR WORK '
..SEPTIC-TANK,-SEEP,.PIT(S) -•- -
ADDRESS- . ..._.__ . ,. _...
._.-.•• `-AND/OR`DRAINFIECD:--- :. _..- � ... .. _ .,. � .. .,� �..�.,..
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION.
AND STATE THAT THE,ABOVE IS CORRECT.AND,AGREE TO_COMP_LY,__ -.CESSPOOL_❑ ..DRYWELL-�' -- •-- -^
WITH ALL COUNTY* ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,-REPAIR,SEWER OR
•SEWAGE,DISPOSAL-SYSTEM------- •• -- -
1' HEREBY -CERTIFY--THAT'"`I 'A'M- PROPERI'Y-REGISTERED'A'NDJOR`.. DISCONNECT PLUG AND _
LICENSED AS REQUIRED LOS ANGELES-COUNTY .AND STATE OF -
CALIFORNIA, OR THAT
,..)LO.THE.,LEGA .,0, ..OF T -.ABOVE .: ABANDON HOUSE SEWER _�_ ,_. ---- _-____._-__ �_ �_„ ,•: <
DESCRIBED RESIDENT 'L�P PERTY. �f BACKFILL SEPTIC TANKS ❑.
SIGNATURE _` _ -SEEP. PITS) ❑ CESSPOOLS -
.. w, _ -. - -- _._ .... .--..._,�..
OF"PERMITTEE - - -
®F ti "'VALIDATION _._ ROBERT A WOOD
c K. m.o. CASH SUPERVISING.MECHANICAL ENGINEER
- - - LAC-o2-10-:8-61-JAN-2-3 1-0- :A