HomeMy Public PortalAbout6123 LOMA AVE_Sewer__ 78A4YD
CH808 8•E9 APPLICATION FOR PERMIT- � -
7 •
COUNTY-OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGMEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
70IN A. LAMSIE, County Engineer
CASSATP D. GRIFFIN, Supt of Building LOCALITY
NEAREST
FORrAPP;LICANT TO FILL IN caoss sr. fie
LEGAL i ,f
DESCRIPTION LOT N0: OWNER ft
BLOCK TACT 4 MAIL - -
-ADDRESS _ I NO OF BLDGS.
SIZE OF LOT NOW ON LOT (�-� CITY TEL NO
USE OF t/�
BUILDINGS f�-' DISTRICT N0. GROUP MAP RBY
CONTRACTOR C J! v 7PI Jj
ADDRESS CONNECTION DATA/ '
CITY TEL.NO, Q '� STATION Z DEPTH
REGISTRATION NO. l O l Z COUNTY LOWER MANHOLE REFERENCE ry
L
No. , DESCRIPTION OF WORK FEE ,
HOUSE SEWER CONNECTING TO
PUBLIC SEWER 1, @ $3 00 60 TYPE OF CTION ,.LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. U'RB P.L. M.L.
TO P.L.
PITS AND/OR DRAINFIELD @ S3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1 00 CO.IMP. N0. JOB NO.
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT N0. ROAD PERMIT N0. _
WORK TO HOUSE SEWER @ St 00 i
ALTER,REPAIR OR ABANDONHOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1 00 PERMIT N0.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE —S-60 REIMBURSEMENT FEE
NAMED CON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTIDATE A CONTRACT WITH THEING DWELLING APPROVALS DATE / INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS / DAY OF 19 NEW HOUSE SEWER :70,
OWNER OR / CONNECT ADDITIONAL '
OWNERS AGENT w� y BUILDING OR WORK
ADDRESS I ` % SEPTIC.TANK,SEEP.PIT(S) _
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS.
SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDE�ALPRO ERTY. BACKFILL SEPTIC TANKS ❑
SEEP PIT(S) ClCESSPOOLS
SIGNATURE
OF PERMITTE
®' VAIMATIOROBERT A. WOOD'
CIL H.p. Q H SUPERVISING MECHANICAL ENGINEER
f - R ^� 1 .r