HomeMy Public PortalAbout6141 LOMA AVE_Sewer__ 642D 90-63
76AAPPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAG DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO ' OWNER
( MAIL
BLOCK TRACT JADDRESS
NO OF E510 GS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP BK MAP PG PROCESSED BY
BUILDINGS
CONTRACTOR ^O� 72-
ADDRESS f CONNECTION DATA
CITY L NO 47 STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO COUNTY LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L ML TO P L }
PUBLIC SEWER @ $s 00 PC NO tl
SEPTIC TANK,SEEPAGE PIT OR
NO
PITS ANO/OR DRAINFIELD @ SIO 00 CO IMP NO JOB NO
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ 83 00 IX
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER 1�11MINT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT,DRAINFIELD l!J
EXTN CESSPOOL,DRYWELL,MANHOLE @ SS 00 pL
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING to
SEWER OR DISPOSAI.SYSTEM @ S300 STATE ENCROACHMENT /
PERMIT NO
INDUSTRIAL �✓-
All WASTE APPROVAL
CHARGES
OWNERS 4ERMIT $ 2 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL �l
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINgIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL Cl
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 THE LEGAL O . AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOV S RIBED R I E T L PROPERT ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
ov
M O CASH
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6A(o4 t°-63`-
76Ar;42D APPLICATION FOR PERMIT
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COUNTY 6F LOS ANGELES. SEWER-SEWAGE DISP SAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
1..111.T1
NEAREST
FOR APPLICANT TO FILL IN CROSB ST
LEGAL C
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT 0 ADDRESS /VQ
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
BK P
G
CONTRACTOR �
ADDRESS 2 L.(0 CONNECTION DATA
CITY L ` E "T�L NO 7 (p NCE STATION \ DEPTH
`' STATE MANHOLE REFERE UPPER
REGISTRATION NO V tl COUNTY D� i
NO DESCRIPTION OF WORK FEE TYPE Okq,6110N LENGTH FR
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L
PUBLIC SEWER @ $B 00 PC NO EL
SEPTIC TANK,SEEPAGE PIT OR JOB NO O
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO /►
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO C� �� U
PRIVATE DISPOSAL SYSTEM @ $3 00 cz
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ S300 (—
OVERFLOW SEEPAGE PIT,DRAINFIELD V
EXTN CESSPOOL,DRYWELL MANHOLE @ EB 00 -
W
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING d.
rn
SEWER OR DISPOSAL SYSTEM @ S3 00 STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S 2 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF
OWNER OR NEW HOUSE SEWER
OWNERS AGENT v
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTYORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TH AM THE LEG ER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A VE DESCRNE! D R S TIAL PR ER7Y ABANDON HOUSE SEWER
SIGNATURE �J BACKFILL SEPTIC TANKS ❑
OF PERMITTEE LWC SEEP PIT(S) ❑ CESSPOOLS ❑
VM O CASH ALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK
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