HomeMy Public PortalAbout6163 LOMA AVE_Sewer__ 1 I
764 2D 5-65
6AAPPLICATION FOR PERMIT -
6A64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION' BUILDING C /
JOHN A. LAMBIL. County E 7
Engineer . ADDRESS 143 � 7 22
s
COLEMAN W. JENKINS,Sup't. of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS $T, P
LEGAL Iq
DESCRIPTION LOT NO. gJED OWNER �(
D .` MAIL
BLOCK TRACT �/�- ADDRESS 7
NO. OF SLOGS.
SIZE OF LOT - NOW ON LOT CITY (`j TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
BK (/J PG //n
CONTRACTOR *�� Ide,{, /i
ADDRESS — H CONNECTION DATA' III (. .
O STATION / �I DEPTH
CITY TEL. NO. / L/
LICE SEE '� - / P 12
NO. CLASS MANHOLE REFERENCE LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CON TION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. URB P.L. M.L.TOP.L.
PUBLIC SEWER C $ 5.00
SEPTIC TANK, SEEPAGE PIT OR P.C.NO. a
PITS AND/OR GRAINFIELD C $10.00 CO. IMP.NO. - JOB NO. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. u
PRIVATE DISPOSAL SYSTEM C $ 3.00
CONNECT ADDITIONAL BLDG. OR I� A
K AFFIDAVIT waIYER EnSEMENT RECORD. INSTR.NO. DATE O
WORTO HOUSE SEWER C $ 3.00 U � •/
A T R, REPAIR OR ABANDON HOUSE ()
SEWER OR DISPOSAL SYSTEM C $ 3.00 W
OVERHWY. OR ST.WIDENING d
Ny
EXTN.,CESI-OWSPOOL. MSEEPAGEANHPITOLE C $ 5.00 STATE ENCROACHMENT b
PERCOLATION TEST C $ 5.00 PERMIT NO. _
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s1 21 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE
AHAVE 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 INSPECT R'S SIGNATURE
SIGNED THIS DAY OF
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL f Y
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP.PIT(S) -
I HEREBY ACKNOWLEDGE THAT I HAVE READTHIS APPLICATION AND/OR DRAINFIELD -
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR.
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO, DISCONNECT PLUG AND _
RESIDE IN, THE ABOVE DESCRIBED .RESIDENTIAL PROPERTY. / ABANDON HOUSE SEWER Z f
SIGNATURE ! BACKFILL SEPTIC TANKS El � -^-
OF PERMITTEE ✓ SEEP.PIT(S) ❑ CESSPOOLS 01 ,f 9/JPS
VALIDATION
CK. M.O. CASH
LAGo :�, g o y 'MAY 3'.1 1 0 D 1 0.0 a N ,