HomeMy Public PortalAbout6111 LOMA AVE_Sewer__ DEPAWMENT OF COUNTY ENGINEER ' . SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX. COUNTY ENGINEER I BUILDING
ADDRESS
FOR APP/LIX T L IN LOCALITYBUILDING
NES
ADDRESS rL L CROSS ST.
LOCALITY DISTRICT . SERIAL NO. PERMIT NO.
NEAREST A J
CROSS ST. RECEIV B Ready for Inspection DATE ISSPD
OWNER • !//// (/�j 3
MAIL f ADDRESS USE ZONE OCCUPANCY �l17AF*
K
CITY TEL.NO.
CONTRACTOR
+� CO.IMP.N0. O i/
ADDRESS O w
JOB N0.
CIT TEL.gO. QTRUNK PERMIT NO.
STATE
REGISTR ION NO. ., (� a ❑ COUNTY ROAD PERMIT NO. �/g
LEGAL . 4 7/2 STATE ENCROACHMENT
DESCRIPTION LOT NO ¢ T 2 S PERMIT NO.
BLOCK TRACT �� Q INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT XlI3NO.OF•SNOW ON LOTS CHARGES
USE OF
BUILDINGS CONNECTION CHARGj FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO _'{ REIMBURSEMENT FE
PUBLIC SEWER @ $ 3.50 C✓ RECEIPT NO. DATE I BY
HOUSE SEWER CONNECTING TO `
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR CEPT N RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING O I ATE 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
IOF
TS AND/OR DRAINFIELD 2.00 STATIONI ��i DEPTH
CESSPOOL—DRYWELL �
SPECIAL CONDITIONS ONLY _ 2.00 T ANHOLE REFERENCE
OWE ,
TYPE OF CTION LENGTH FROM
OWNERS PERMIT $ 1 00 cuR6 M.L.TO P.L. V
AUTHORIZATION I TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HER IN NAMED
\. CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THS PUBLIC SEWERAPPROVALS INSPECTOR'S SIGNAT RE DATE
1'S APPROVALS
SIGNED THIS/JAY OF.... NEW HOUSE SEWERp !
OWNER OR CONNECT ADDITIONAL
►- OWNERS AGENT ....
_..._. -- BUILDING OR WORK
r
% SEPTIC TANK,SEEP.PIT(S)
ADDRESS-..- ..'----- ----- - ----- -------------- - ---- -------•-- AND/OR DRAINFIELD
IHEREBY ACKNOWLEDGE THA I HAVE READ THIS APPLI- CESSPOOL[:] DRYWELL E]
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 DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THA AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RE NTIAL PROPERTY. BACKFILL SEPTIC TANKS _
SIGNATURE SEEP.PIT(S)[:] CESSPOOLS
OF PERMITTEE__ _---
76A642D 663 1/53 G I j<