HomeMy Public PortalAbout6127 LOMA AVE_Sewer__ ? 0�
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76A(142APPLICATION FOR PERM -r
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ! .�/ld
ADDRESS /"���TT
JOHN A. LAMBIE. County EngfnPdelrng
WILLIAM A. JENSEN, Sup't of BB LOCALITY
NEAREST
FOR APPLICANT TO FILL IN ceoss sT. ( .V
LEGAL
DESCRIPTION LOT.NO OWNER
BLOCK TRACT J� , 1 MAIL -
ADDRESS
NO OF BLDGS.
SIZE OF LOT NOW ON LOT �. CITY TEL NO. -
USE OF �J DISTRICT N0. ROUP MAP PRQ,�ESSED BY
BUILDINGS ES /T/� C HK PG /./)
CONTRACTOR ` E SO _� r
ADDRESS AJAI f %O1,/ CONNECTION DATA -
CITYr)WI P I!! EL N0. STATION '3'�•' DEPTH -
,,!! STATE +MANHOLE REFERENCE
REGISTRATION NO t�.5 �'fV —T Z.••' �❑ COUNTY 1 OWER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TOJL t Ar)
PUBLIC SEWER @ $ 00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $ 00 i
OVERFLOW SEEPAGE PIT DRAINFIELD -
EXTN CESSPOOL DRYWELL @ $ 00
O.
HOUSE SEWER CONNECTING TO P.B O.
PRIVATE DISPOSAL SYSTEM @ $ 00 CO IMP. N0. JOB N0. W
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD'PERMIT NO. - - V
WORK TO HOUSE SEWER @ $ 00
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT p4
SEWER OR DISPOSAL SYSTEM @ $ 00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL W
CHARGES
OWNERS PERMIT $ Z '00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE (90 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING-DWELLING - APPROVALS DATE/ INSPECTOR'S,SI6NATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OFA 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK -
ADDRESS SEPTIC TANK,SEEP PIT(S)
AND/OR DRAINFIELD
1 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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND _
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF –±BANDON HOUSE SEWER - -
CALIFORNIA OR
T T I AM THE LEGAL NER OF THE ABOVE
DESCRIBED RESID TIA PROP TY BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS ❑
OF PERMITTE
Or ALIDATION ROBERT A. WOOD
O
M.o, CASH SUPERVISING MECHANICAL ENGINEER