HomeMy Public PortalAbout6164 LOMA AVE_Sewer__ CE8
76A°642D-68 APPLICATION; FOR PERMIT'. - - -
CQUNTY",OF LOS ANGELES SEWER-SEWAGEMISPOSAL.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION; BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDdessp, G7U_7ROCESSED
COLEMANW. JENKINS,-SUPT. ofBUILDINGLOCALITYNEARESTFOR' -APPLICANT TO FILL IN ' CROSS ST. aLEGALDESCRIPTION LOTNO. � OWNERMA1LBLOCK - TRACT - ADDRESSNO. OF BLDGS. ,.SIZE OFLOT NOW ON LOT CITY TEL. NO.`
USE OF , - f . -BULDINGSDISTRICTNO. GROUPMAP
- - G SK PG
CONTRACTOR O CF VJ
ADDRESS _ /�"` �' CONNECTION.DAT�I
CITY ' ��'- 3L. NO. G _ —Z STATION,'" - DEPTH
STA TE �J LIC - / MANHOLE-REFERENCE UPPER
LICENSE NO: QCCL A'SS fG/ -, - LOWER
NO. ,E)ESCRI.PTION OF WORK FEE TYPE OF CONNECTION - LENGTH FROM
HOUSE SEWER CONNECTING TO - Y. CURB P.L. MA_TO P:L-. 1
PUBLIC SEWER $5.00 - -
SEPTIC TANK,SEEPAGE PIT OR - P.C.;NO.-
PITS AND/OR DRAINFIELD- $10.00 - CO:IMP. NO. JOB'..NO. 1 ._
HOUSE SEWER CONNECTING TO L TRUNK PERMIT NO.' ROAD.PERMIT NO.
PRIVATE DISPOSAL SYSTEM' $3.00 d
'
CONNECT ADDITIONAL BLDG.OR _ -AFFIDAVIT WAIVER EASEMENT RECORD. INSTR.NO. BATE C�
WORK TO-HOUSE SEWER @ '$3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD -
.� I - --
XTN.,CESSPOOL.DRVWELI.MA NH OLE @ $5.00
ALTER. .HOUSE HWY..OR ST.WIDENING - V
SEWER SYSTEM � $3.00 0 d STATE ENCROACHMENT 4J� �. Q.. D_
- PERMIT NO. - fJ)
INDUSTRIAL
WASTE-APPROVAL !/
"
WNER'S PERMIT �$- z oo CHARGES
� .'
ATTTuv`HO�`RiZATION TOTALTEE O D CONNECTION CHARGE FEE ,
I. HAVE AT THIS DATE A."CONTRACT WITH THE HEREIN.NAMED-CON. REIMBURSEMENT FEE
TRACTOR TO-CONNECT THE ABOVE DESCRIBED EXISTING DWELLING _ }� p
TO THE PUBLIC SEWER. - �. _ - APPROVALS DATE INSP ECTOR'.S SIGNATURE
SIGNED THIS 'DAY OF "19_ - -
OWNER OR - - NEW HOUSE'SEWER -
OWNERS AGENT_ CONNECT ADDITIONAL•'
. 'ADDRESS -
- BUILDING OR WORK -
.SEPTIC TANK;SEEP,PIT(S) "
IDHEREBY ACKNOWLEDGE THAT I HAVE•READ THIS APPLICATION AND/OR DRAINFIELD "
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY -
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING _ -
.PLUMBING AND SEWERS. CESSPOOL •❑. DRYWELL ,❑.
HEREBY R
Y CERTIFY THAT I AM. P OPER Y REGISTERED AND/OR ALTER,REPAIR, R'
LICENSED
AS REQUIRED BY LOS NGLE OUNTY AND STATE OF SEWAGE DISPOSALAL SYSTEM
CALIFORNIA OR THAT f RM'THE GAL. NER OF, AND INTEND To
RESIDE IN. THE�ABOVE DESCR ED RE ENTIAL PROPERTY. -DISCONNECT PLUG AND _
ABANDON SEWERSIGNATURE" - BACKFILL SEPTIC TANKS El-
SEEP.
- -
OF PERMRTEE SEEP.PIT(S) ❑ ,CESSPOOLS ❑,
AUDATION JACK R. ALLEN
'SUPERVISING' MECHANICAL ENGINEER '
CK. M.0
. CASH - _