HomeMy Public PortalAbout5941 LOMA AVE_Sewer__ D
6&E-663 3.56 9tl ALICA ■ ION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL.
Department of County Engineer
County of Los Angeles BUILDING
WM.J.FOX, COUNTY ENGINEER ADDRESS t7"�111 G� ,
CASSATT D.GRIFFIN,SUPT OF BUILDING LOCALITY
s
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL ,15 2
DESCRIPTION LOT N0. O� OWNER �
BLOCK TRACT '� '/ MAIL
ADDRESS
y / Y «�
SIZE OF LOT
5_/r, /�t) NOWOON LOTS CITY t TEL. NO. 9 cZ„
USE OF
7 _BUILDINGS �`" "V � DISTRICT N0. GROUP MAP
SK PG
CONTRACTOR -
oe
ADDRESS �,2 ?2qq - CONNECTION DATA - .
CITY TEL. NO. / y y 'STATION / 1�+ i DEPTH
t STATE MANHOLE REFERENCE f0/�
REGISTRATION NO. ) ❑ COUNTY - /V
NO. DESCRIPTION OF WORK 'FEE TYPE 0 NNECTION LENGTH FROM
HOUSE SEWER
CONNECTING TO S..�q Y. CURB P.L. M.L. TO P.L.
PUBLIC SEWER r $ 3.50 VV
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR P.B
WORK TO HOUSE SEWER 1.00 � .CO. IMP. NO. �•(j JOB NO.
ALTER OR RPAIR
SEWER OR DISPOSALS SITEM 1.00 TRUNK PERMIT NO. ROAD.PERMIT NO. 10
.DISCONNECT AND ABANDON SEWER - STATE ENCROACHMENT
DISPOSAL SYSTEtA 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR -
ITS AND/OR DRAINFIELD 00 INDUSTRIAL.
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 I CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT s 1 00
AUTHORIZATIONS I TOTAL FEE j7 REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED ✓CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER,
SIGNED THISDAYOF 19 NEW HOUSE SEWER _ —2fS!
OWNER OR CONNECT ADDITIONAL
OWNERS A G E N BUILDING.OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL[I DRYWELL ElAND 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
LICENSED AS REQUIRED BY LOS ANGELES COUNTY- AND STATE OF DISCONNECT.PLUG AND
CALIFORNIA. OR THAT I AM THE. LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPT-IC TANKS❑ - .
SEEP. PIT(S) ❑ CESSPOOLS
SIGNATURE ' .. /�.s� , .. Q
OF PERMITTEE /" ,- Pr
WILLIAM J.FOX, COUNTY ENGINEER VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR
t� :05 0 5N JUL 23 5.5
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