HomeMy Public PortalAbout6003 LOMA AVE_Sewer__ S&E-6D APPLICATION F'OR PERMIT
1
5&E-669 11.55 �l
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Depcatment of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
T) CASSATT D. GRIFFIN, SUPT OF BUILOLNG
LOCALITYJ_
NEAREST f
FOR APPLICANT TO FILL IN CROSS ST.. e•' „
LEGAL 49
DESCRIPTION LOT NO. OWNER o�}• �r
MAIL
BLOCK l,��T�RACT - ADDRESS
SIZE OF LOTr
`' SNOW ONLOTS CITY �"y„y�„ TEL. NO.
USE OF
BUILDINGS L� �'{"� C�,..•aa C` DISTRICT NO. GROUP BK
�---�-- B K PG
CONTRACTOR ~��►��� _ a. � � � -
,/f /�/// ✓ CONNECTION DATA
ADDRESS : yf /c oma' 9"`
01 STATION DEPTH
CITY ` TEL. NO.�f kl I MANHOLE REFERE E j i f UPPER
r' STATE '/ LOWER
REGISTRATION NO. � /�t 0 COUNTY
NO. DESCRIPTION OF WORK FEE
TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB _P}.. M.L. TO P.L.
PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR / $ -
PITS AND/OR DRAINFIELD Q $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. N0.
EXTN.,CESSPOOL,DRYWELL,MAN HOLE Q $2.00 CO. IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT.ADDITIONAL BLDG.OR STATE ENCROACHMENT•
WORK TO HOUSE SEWER Q $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE '`�� INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1.00 wF WASTE APPROVAL
,r
CHARGES
CONNECTION CHARGE FEE -
OWNER'S PERMIT $ 1 00 r '
AUTHORIZATION TOTAL FEE -,)-I
co
; REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON✓- APPROVALS v /D,ATTEE! INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK;SEEP,PIT(S)
ADDRESS - AND/OR DRAINFIELD
I H EREBY'ACKNOW LEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL[__1DRYWELL E3AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER EPAIR,SEWER OR
PLUMBING AND SEWERS. E DISPOSAL SYSTEM
I HEREBY CERTIFY. THAT I AM PROPERLY R TERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES C TY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT ,AM THE LkEG L �NER OF THE A OVE
DESCRIBEDRESIDENTPROPERTY. { BACKFILL SEPTIC TANKS❑SIGNATURE _ SEEP.PIT(S) ❑ CESSPOOLS❑OF PERM]TTE
JOHN A. LAMBIE. C .
. TY ENGINEER IDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
C M. 0. CASH
`o 2 6 2 7011 jUL 8' 1 A 2'.0 0
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