HomeMy Public PortalAbout6148 LOMA AVE_Sewer__ 78A842D' I,
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COUNTY OF LOS ANGELES •SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILD
BUILDING AND SAFETY DIVISION' NG
ADDRESIS
rrCON A. LAMMIE, County Engineer
CASSAIT D. GRIFFIN, Supt of Building LOCALITY
NEAREST -
FOR APPLICANT TO FILL IN ?s, CROSS ST. $ 1441
LEGAL
DESCRIPTION...- -'LOT NO. Y- .OWNER „1 •r
BLOCK TRACT �. Q� - MAIL
ADDRESS
0 OF BLDGS. -
SIZE OF LOT NOW ON LO CITY TEL NO.
USE'OF PIS,TRICT,NO 'GROUP MAP PROCESSED BY
BUILDINGS
BK PG
CONTRACTOR
`s
A
ADDRESS CONNECTION DATA
CITY TEL.NO. Q STATION DEPTH
B�6IATE MANHOLE R E N E - UPPER
REGISTRATION NO. ❑ COUNTY - LOWER
NO DESCRIPTION OF WORK FEE +
HOUSE SEWER CONNECTING TO D
PUBLIC SEWER @ $3 00 TYPE OF CONNECTION LENGTH PROM
P ITS AND/OR DRAINFIELD T OR @ S3 00 Y. CU B P. M.L.TO P.L. '
OVERFLOW SEEPAGE PIT,DRAINFIELD J l _
EXTN CESSPOOL DRYWELL @ $2.00 _
HOUSE SEWER CONNECTING TOP.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1 00 4/116. NO., JOB NO.
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ SI 00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
EWER OR DISPOSAL SYSTEM @ $100 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERF 2 00 CONNECTION CHARGE FEE
A=ORMATION TOTAL FEE REIMBURSEMENT FEE
CON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTDATE A CONTRACT WITH THE I+NGAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. '
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER _ v
OWNER ORCONNECT ADDITIONAL
OWNERS AGENT 0&.A r-/ BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 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 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I A T LEGAL�,NERTHE ABOVE _
DESCRIBED RESIDE P P Y BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS ❑
OF PERMITTE
ip
Or VALIDATION ROBERT A. WOOD
Y
CL .G• CASH SUPERVISING MECFIANICAL ENGINEER
' ^ 11