HomeMy Public PortalAbout6205 LOMA AVE_Sewer__ 76A642D 64 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES DISPOSAL
S P L
DEPARTMENT OF COUNTY ENGINEER SEWER-SE G E OSA
BUILDING AND SAFETY DIVISION BUILDING /� y
JOHN A. LAMBIE, County Engineer ADDRESS qi
WILLIAM A. JENSEN, Sup't of Building
LOCALITY -
NEAP.EST '
FOR APPLICANT TO FILL IN `ROSS ST. �--
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL �►
BLOCK TRACT ADDRESS
NO. OF BLOCS.
SIZE OF LOT NOW ON LOT
USE OF DISTRICT NO. GROUP MAP. PROCESSED BY
BK BUILDINGS
CONTRACTOR "C R_. ` 7� �rs/ PG
ADDRESS j ✓ CJV/� q. /C��ONNECI DATA
./Y �.. SEL. N �r� / STATION {�-'`/_/Sd,... , DEPTH
El C (1(-192 ❑ COUNTY MANHOLE R F.2`N�E S:, O r U
PPER
REGISTRATION Nb Ju
Njf. DESCRIPTION OF WORK FEE TYPE OFM ION V LENGTHFROM
HOUSE SEWER CONNECTING TO �/` Y P.L. ATO P.L.
PUBLIC SEWER @ $5.00
Pe NO. }
SEPTIC TANK,SEEPAGE PIT OR CO.IMP. NO. OB NO. • d
PITS AN OR DRAINFIELD @ $10.00 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERM[
A
PRIVTE DISPOSAL SYSTEM @ S3.00 v
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER [ASEM RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 O
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRY.WELL,MANHOLE @ $5.00Uj
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WID ING h
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENC CHMENT
PERMIT
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ z 00
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 INSPECTO,IS SIGNATURE
SIGNED THIS _ DAYYAOFT 19_
OWNER OR try/ - / NEW HOUSE SEWER °
OWNERS AGENT /, ��((L//��� CONNECT ADDITIONAL fF
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
'1 HEREBY 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 ❑
LPLUMBI.ENGAND SEWERS. - CESSPOOL ❑ DRYWELL CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
AS REQUIRED BY LOS ANGLES TY AND STATE OF SEWAGE DISPOSAL-SYSTEM
A WTHATM THE LEGAL O NER F, AND INTEND TO DISCONNECT PLUG AND TDESCRIBED 5 ENTI L' PROPERTY. ABANDON HOUSE SEWERBACKFILL SEPTIC TANKSI ❑
SEEP,PIT(S) ❑ CESSPOOLS
VALIDATION SUPERVISING MECHANICAL ENGINEER.ROBERT A. WOOD
CK. M.O. GASH -
1into . 10 GOT 92UU BOG