HomeMy Public PortalAbout6120 LOMA AVE_Sewer__ 76AC42D _APPLICATION FOR PERMIT 1
S&E-663 11.55
DIVISION OF BUILDING AND SAFETY -SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los AngelesBUILDING - `
JOHN A LAMBIE. COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN, SUP T OF BUILDING - - LOCALITY ,
FOR APPLICANT TO FILL IN CROSS ST
LEGAL ` o,
DESCRIPTION LOT�NO dO MUk� •O OWNER
BLOCK TRACT ��� MAIL
(.� ADDRESS
N0. OF BLDGS CITY — - TEL NO
SIZE OF LOT NOW ON LOT
USE OF /
BUILDINGS DISTRICT NO GROUP MAP'� I _•, P
CONTRACTOR ,�� IL�(,����•
ADDRESS CONNECTION DATA77 '
�l STATION q, DEPTH
CITY TEL. NO. lQ L
MANHOLE REFERENCE �^ U
TATE OWER
REGISTRATION N0. 6-7 v ❑ COUNTY _
NO' DESCRIPTION OF WOR FEE
p HOUSE SEWER CONNECTING TO - TYPE OF TION LENGTH FROM '
1 Y. URB j PL ML.TO PL
PUBLIC SEWER @ $3 50
SEPTIC TANK,SEEPAGE PIT OR
h PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT, DRAINFIELD P C. N0.
EXTN ,CESSPOOL,DRYW ELL,MANHOLE Q $2 00 CO IMP. NO l� 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 @ $1 00 PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERNUT $ 1 00
REIMBURSEMENT-FEE
AUTHORIZATION TOTAL FEE - - -
I HAVE AT,THIS DATE A CONTRACT WITH THE HEREIN N MED CON.
APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE-PUBLIC SEWER - NEW HOUSE SEWER
SIGNED THIAY OF 19 CONNECT ADDITIONAL
OWNER ORBUILDING OR WORK -
OWNERS AGENT , �^ SEPTIC TANK,SEEP,PIT(S)
ADDRESS n A '1':. •� i. AND/OR DRAINFIELD '
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL O DRYWELL❑ '
AND 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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER -
CALIFORNIA OR TH I AM THE LEG,L OWNER OF THEY ABOVE rr��
DESCRIBED RESIDEN IA PRO RTY' l e
SEEP SEP ❑ CESSPOOLS
SIGNATURE
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A WOOD, CHIEF PLBG INSPECTOR'
CK. N 0 •CASH
4 4 7 31; NOV 20 4 4.5-0