HomeMy Public PortalAbout6126 LOMA AVE_Sewer__ 6'&E fi-6•8D ;8S 11,Ss APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE, DISPOSAL
Depas ent of County Engineer
County Of Los Angeles BUILDING ee��
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS /p[•� ���Y��JLs
® - CASSATT D GRIFFIN, SUP'T of BUILDING LOCALITY ,
FORA/0 PPLI_C TO.FILL IN CROSS ST. "
LEGAL ' OWNER �� p
DESCRIPTION LKy
MAIL
BLOCK = TRACT - ADDRESS
N0. OF BL -�L_ CITY - TEL NO.
SIZE OF LOT NOW ON LOTT
USEUSE OF
DINGS DISTRICT NO GROUP MAP
BK PG
CONTRACTOR
ADDRESS - CONNECTION DATA -
_ STATION DEPTH
TY /.C/�./
CITEL. NO. �T
MANHOLE REFERENCE
J6¢70/ 1- STATE r LOWER
REGISTRATION NO. - ❑ COUNTY .
NO DESCRIPTION OF WORK FEE -
TYPE OF CTION - LENGTH FROM
HOUSE SEWER CONNECTING TO Y. C R P L M L.TO P.L. CJ
PUBLIC SEWER - @ $ C _
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3 00 ,
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C:NO.
EXTN ,CESSPOOL,DRYWELL,MANHOLE @ $2 00 CO IMP NO.1 10B NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO. - ROAD PERMIT NO.v,
CONNECT-ADDITIONAL BLDG OR STATE ENCROACHMENT -
;WORK TO HOUSE SEWER @ $1 00 PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL r -
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE-APPROVAL l - -
CHARGES
CONNECTION CHARGE FEE -
OWNER'S PERMIT s 00
AUTHORIZATION TOTAL FEE 41 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE-HEREIN NAMED CON.
APPROVALS'- DATE - INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING -
TO-THE PUBLIC SEWER - NEW HOUSE SEWER
SIGNED THIS DAY OF194 CONNECT ADDITIONAL
OWNER OR �oS BUILDING.OR WORK
OWNERS AGENT - SEPTIC TANK,SEEP, PIT(S) -
ADDRESS - AND/OR DRAINFIELD - - -
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ 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 THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS _
OF PERMITTEE
JOHN A LAMBIE, COUNTY ENGINEER VALIDATION ROBERT Al WOOD,,CfAIEF PLBG INSPECTOR
• V CK N O.
L&1 4 ,6 8,°; DEC 31 1 0 A 5.0'0