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Home My Public Portal About5756 LOMA AVE_Sewer__ 2/70 76.A APPLICATION FOR PERMIT 76,A 642D COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS COLEMAN W. JENKINS. SUPT. OF BUILDING �G LOCALITY' FOR APPLICANT TO FILL IN NEAREST CROSS ST, o- (P.RINT OR TYPE ONLY) _ LEGAL DESCRIPTION LOT NO. OWNER)/i/,� MAIL %-- BLOCK TRACT ADDRESS NO. OF SLOGS. SIZE OF LOT NOW ON LOT CITY TEL. NO. ' USE OF ' BUILDINGS DISTRICT NO. GROUP CLASS MAP ROLE SS ED BY BK PG CONTRACTOR '� L 5 0 . ADDRESS VVV CONNECTION/DATA CITY Te NO. STATION ..�/�(J' DEPTH _ (/��i ��]] STATE 7 GLASS LIC LICENSE NO;, MANHOLE REFERENCE LOWER 1/ NO. I DESCRIPTION OF WORK FEE TYPE.OF CON ION LENGTH ROM HOUSE SEWER CONNECTING TO `J Y. j P.L. M.L.TO P.L. PUBLIC SEWER @ $5.00 (/' SEPTIC TANK.SEEPAGE PIT OR -2,�/ P.C.NO. PITS AND/OR DRAINFIELD @. $10.00 CO.IMP.NO. / JOB NO. HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NOJ/�� } PRIVATE DISPOSAL SYSTEM @ $3.00 . .� d CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER '[AS[MCNT RECORD. INSTR.NO. DATE O WORK TO HOUSE SEWER @ $3.00 lJ OVERFLOW SEEPAGE PIT.DRAINFIELD EXTN.,CESSPOOL.DRYWELL.MAN HOLE @ $5.00 . ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING O 0 SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT IJ PERMIT NO. LLL O. INDUSTRIAL Z WASTE APPROVAL OWNERS PERMIT S 00 CHARGES AUTHORIZATION I TOTAL FEE W� CONNECTION CHARGE FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEW R APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS D Or 19_ OWNER OR � �!/�' � NEW HOUSE SEWER OWNERS AGENT P CONNECT ADDITIONAL ADDRESS BUILDING OR WORK SEPTIC TANK,SEEP.PIT(S) I HEREBY ACKNOWLEDGE THAT 1 HAVE"READ T IS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND GREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ' PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ 1- HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR LICENSED AS REQUIRED �Y LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I R THE LEGAL OWNEF. AND INTEND TO - DISCONNECT PLUG AND RESIDE IN, THE ABO DESCRIBED REI ENA PROPERTY. ABANDON HOUSE SEWER SIGNATURE `r OF PERMTTIBACKFILL SEPTIC TANKS ❑ TFE� /� �/� SEEP.PIT IS) ❑ CESSPOO VAL TION JACK R. ALLEN M.-O. CASH SUPERVISING MECHANICAL ENGINEER _ - CK. I CE808 2D7D 7,6,A 642D APPLICATION FOR PERMIT - � - COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION eU1LDwG � JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS J COLEMAN W. JENKINS'. SUPT. OF BUILDING v _ LOCALITY,.FOR APPLICANT TO-FILL IN TZ NEAREST (PRINT OR TYPE ONLY) cR055 ST. r'-' �///� LEGAL - VV" / A/ / DESCRIPTION LOT NO. OWNER MAIL BLOCK TRACT ADDRESS P NOOF BLDGS. G 1 M SIZE OF LOT ON LOT. CITY - TEL. NO. USE"OF' .. - BUILDINGS, DISTRICTNO. GROUP CLASS MAP BK pR(,CESSED BY ' CONTRACTOR - - 1" ADDRESS j CONNECTION DATA CITY TEL NO. STATION DEPTH ATE. LIC z- - UPPER ST LICENSE 'NO: C%' CSL ASS MAN LE REFERENCE LOWER No. ,DEc; TION OF WORK. FEE TYPE'O ONNECTION LENGTH FROM,. HOUSE SEWER CONNECTING TO Y. U,RB P:L. M.L.TO P.L. .PUBLIC SEWER @ $5.00 • - SEPTIC TANK.SEEPAGE PIT OR •`P:C.NO. PITS AND/OR DRAINFIELD $10.00 CO. IMP. NO. .,` JOB NO. - HOUSE SEWERCONNECTING TO TRUNK PERMIT NO. ROA RMIT NO. .PRIVATE DISPOSAL SYSTEM �' $3.00 _ O CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WANE? "EASEMENT ORD.-I'NSTR. NO. DATE WORK TO HOUSE SEWER @ $3.00 C3 \� V OVERFLOW SEEPAGE PIT.DRAINFIELD EXTN..CESSPOOL.DRYWELL,MANHOLE C $5.00 WI OR ST. IN !` O , - •�, F- ALTER.REPAIR OR ABANDON HOUSE - HWY. G "v SEWER OR DISPOSAL SYSTEM C $3.00 STATE E - OACHMENT ' ``` W PER NO. \� USTR IAL tf) :+WASTE,A.PFIROVAL - Z CHAR n OWNERS PERMIT s oo _ , CONNECTION CHARGE F AUTHORIZATION1 TOTAL FEE tog D I HAVE.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 �. - DAYZ�4�� 19` - OWNER OR t NEW HOUSE SEWEROWNERS AGENT / CONNECT ADDITIONAL ADDRESS BUILDING OR WORK SEPTIC TANK.SEEP,PIT(S) .1 -H EREBY�ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD ' AND STATE -THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES- AND STATE LAWS. REGULATING PLUMBING AND SEWERS. - - - CESSPOOL ❑ DRYWELL ❑ I"HEREBY CERTIFY TH T I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR - LICENSED AS REQUIRED' Y LOS ANGLES C NTY AND STATE OF SEWAGE DISPOSAL SYSTEM - CALIFORNIA OR THAT M.THE'LEGAL OW OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE A.0 DESCRIBE IDL PROPERTY. ABANDON HOUSE SEWER - SIGNATUREL��\ BACKFILL SEPTIC TANKS '❑ OF PERME \ SEEP,PIT(S) ❑ CESSPOOLS Ell I ALIDATION JACK R. ALLEN SUPERVISING MECHANICAL ENGINEER CK. M.O. ,CASH `� . .