HomeMy Public PortalAbout6013 LOMA AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER .I ADDRESS
FOR APPLICANT.TO FILL IN LOCALITY
BUILDING
NEAREST
ADDRESS CROSS ST.
LOCALITY I' DISTRICT NO. SERIAL NO. 2 PERMIT NO.
NEAREST- l.. '
A /7 7-f S
CROSS ST. I -RECEIVE air BY Ready for lnspectien DATEISSUED
OWNER ; jr/
MAIL USE ZONE OCCUPANCY MAP
ADDRESS 1 BK �PjG
CITY T 0.� 'i �00 0 < '�"'..li / / .
CONTRACTOR i r
Id CO.IMP.NO. � 9
ADDRESS - L f —
JOB N0.
CITY EL. TRUNK PERMIT NO.
❑ STATE
REGISTRATION N0. ❑ COUNTY, ROAD PERMIT N0.LEGL
DESCRIPTIOd6'j � ®Lf STATE ENCROACHMENT
LOT N0. PERMIT N0. '
BLOCK. TRACT INDUSTRIAL
SWASTE APPROVAL '
SIZE OF LOT OF BLT CHARGES
� W ON LOT /
USE OF
BUILDINGS ( CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO 3
PUBLICSEWER @ $ 3.50 J SZi RECEIPT NO. DATE IBY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR t EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO. I DATE I BY
_SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 _ CONNECTION DATA .
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00. STATION DEPTH'
/
CESSPOOL—DRYWELL �—
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENJDE}
/ � S SLOWER
_ TYPE OF ECTION LENGTH.FROM
OWNERS PERMIT ; I 00" Y. CURB P.L. M.L.TO P.L.
AUTHORIZATION- I TOTAL FEE ' ('
HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED•, —�~
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING; APPROVALS r INSPECTO,R'SSIGNATURE DATE,/
DWELLING THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS
IS_________________DAY OF................................._ 19
OWNER ORCONNECT ADDITIONAL
OWNERS AGENTI .........................1 BUILDING OR WORK
SEPTICTANK,SEEP.PIT(S)
ADDRESS,0 .. �i.._. _,.._._. r�/ _[s!s�`� AND/OR DRAINFIELD
1 HEREBY ACKNOOWLEDGE THAT I HAVE READ THIS AP.PLI. CESSPOOL E] 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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED. AS REQUIRED BY LOS ANGELES COUNTY STATEAND CALIFORNIA THAT
I AM THE LEGAL OWN;' ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RIDPR
QPE TY. BACKFILL SEPTIC TANKS `
SIGNATURE / SEEP.PIT(S) .CESSPOOLSA� 6fj Sl 'j�f
OF PERMITTEE L/ �xC/ r '..!/Y11( - -- --- --- I
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