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HomeMy Public PortalAbout5931 LOMA AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL 9 DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION 1 COUNTY OF LOS ANGELES WILLIAM J. FOX, COUNTY ENGINEER , BUILDING® ADDRESS rl FOR APPLIC NT TO FILL IN LOCALITY BUILDING NEAREST ADDRESS CROSS ST. LOCALITY " DISTRICT'NO. SERIAL NO. PERMIT NO/. NEAREST 5 A CROSS ST. R�E%C`,E�JIVED BY Ready for Inspection S DATE ISSUED- �y�• OWNER .► ��.�r aLr� 7 / / MAIL USE ZONE OCCUPANCY MAP ADDRESS BK PG CITY &23 TEL.NO. 11 / l,� � Ftl : �// / / CONTRACTOR \ N/ Q s.. v.t_9�, 'CO.IMP..N0. / ( � ! U ADDRESS � JOB.N0. CITY . �TEL.N0 t TRUNK PERMIT N0. ` " STATE, e REGISTRATION NO. �' 4C- ��yamO COUNTY ROAD PERMIT NO. TLEGL d DESCRIPTION LOT NO.�,10 �r�1 STATE ENCROACHMENT y-- PERMIT NO. BLOCK TRACT �G�© INDUSTRIAL T- WASTE APPROVAL SIZE OF LOT NO.OF BLDGS. CHARGES NOW ON LOT USE OF BUILDINGS, —w, Yd. CONNECTION CHARGE FEE NO. DESCRIPTION' OFA ORK 4f FEE' REIMBURSEMENT FEE / HOUSE SEWER CONNECTING TO PUBLICSEWER _ _ @ $ 3.50 5 RECEIPT NO. ( ATE I BY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITIONAL BLDG.OR �c EXCEPTION RECORDED WORK TO HOUSE SEWER I.00 NO. I DATjE (BY ALTER OR REPAIR EXISTING SEWER OR DISPOSAL SYSTEM I.00 DISCONNECT AND ABANDON SEWER AND/OR DISPOSAL SYSTEM 1.00 I CONNECTION DATA SEPTIC TANK,SEEPAGE --PITS AND/OR DRAINFIIELDIT OR 2.00 I STATION (� DEPTH CESSPOOL—DRYWELL SPECIAL CONDITIONS ONLY 2.00 I �s MANHOLE REFERENCE A4 UPPER LKfV�£j TYPE OF CONNECTLON LENGTH FROM OWNERS PERMIT $ I 1 00 CURB P,:L. M.L.TO P.L. 1 .AUTHORIZATION • . TOTAL FEE 1513. - I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED' CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING' APPROVALS INSPECTOR'S SIGNATURE -DATE' DWELLING TO THE PUBLIC SEWER r7 NEW HOUSE SEWER 1 SIGNED THISI r.._._..__-DAY OF.. f2�___-_. ISivy_- , �GYI rO t^ 3-/7-,; CONNECT ADDITIONAL OWNER OR BUILDING OR WORK OWNERS AGEN`.. - i - ADDRESS._� _ -1....... i.. SEPTIC TANK,SEEP.PIT(S) _ _ .. _ .......:........... . AND/OR DRAINFIELD i HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI• CESSPOOL[] DRYWELL CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH-ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONFIECT PLUG AND AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY' ABANDON HOUSE SEWER AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN ER OF THE ABOVJVESCRIBED�PESIDENTIAL PROPERTY.. BACKFILLSEPTIC TANKS'Ej.���' SEEP.PIT(S) CESSPOOLS 0' �� ` " SIGNATURE ���" , rt4 OF PERM ,_ �' W 76A642D 663 1/53