HomeMy Public PortalAbout6012 LOMA AVE_Sewer__ 1�7-6A642 D 10-63 APPLICATION FORT PERMIT
6 A 84
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 13UILDENG t V�
JOHN A. LAMBIE, County Engineer ADOREs5
WILLIAM A. JENSEN, Supt of Building ` A^
LOCALiTV CI '
NEAREST ..�`
FOR APPLICANT TO FILL IN `ROSS ST. V
LEGAL ( 1'
DESCRIPTION LOT NO. '� Lq(� OWNERMAIL
BLOCK TRACT r� �+ / ADDRESS '�Ey.- 'l� \� `\v`
�) NO. OF BLDGS. jj
SIZE .1LOT1S O NOW ON 'LOT CITYt C TEL. .NO.
USE OF
BUILDINGS DISTRICT NO. GROUP I MAP PROCESSED BY
BK PG
RelCONTRACTOR �w 1
ADDRESS (0(� V %- CONNECTION DATA
CITY 1f, TEL: NO.{ � \c� I STATION DEPTH
❑ STATE MANHOLE.REFERENCE UPPER
REGISTRATION NO. ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. }
PUBLIC SEWER @ $5:00 - _ P.C.NO. IL
SEPTIC TANK,SEEPAGE PIT OR CO. IMP. NO. JOB NO. "O
PITS AND/OR DRAINFIELD @ S10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ S3.00
CONNECT ADDITIONAL y� `� AFFIDAVIT WAIVER EASEMENT RECORD. INSTR.NO. DATE O
WORK TO HOUSE SEWER @ S3.00 0 V
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ S5.00 a
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING h
SEWER OR-DISPOSAL SYSTEM @ S3.00 STATE ENCROACHMENEv O /J f Z
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ z 00
G CONNECTION CHARGE FEE
AUTHORIZATION TOTAL 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 SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
'CONNECT ADDITIONAL 1�.(f, , .(x/ '�'�s ♦ .
ADDRESS
BUILDING OR WORK
..
SE PTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I .HAVE READ THIS APPLICATION AND/OR DRAINFIELD
.AND STATE THAT THE ABOVE IS CORRECT AND AGREETO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ -
I- HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,.RE PAIR,SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM `
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO .DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER '
SIGNATURE .�^ BACKFILL SEPTIC TANKS ❑
OF PERMIT EE • l ❑
SEEP,PIT(S) ❑ CESSPOOLS
0VALIDATION ROBERT A. WOOD
M.O: CASH
SUPERVISING MECHANICAL ENGINEER
' CK. .,
L; v 4 g aCT 14 1 a o 5,00- P