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HomeMy Public PortalAbout6209 LOMA AVE_Sewer__ 76A6 -62 42D APPLICATION FOR PERMIT 76A642 � COUNTY OF LOS ANGELES SEWER" SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER 'BUILDING'AND SAFETY DIVISION FADDRE ING JOHN A. LAMBIE. COUNTY ENGINEER SSCOLEMAN W. JENKINS. SUPT. OF BUILDING ^ITY. 1 EST FOR APPLICANT TO FILL IN ST. LEGAL pper�\\ �/ DES0 CRIPTION LOT NO. c. `) a !9OWNER TT MAIL BLOCK TRACT © ADDRESS C �+ NO. OF BLDGS.- SIZE OF LOT NOW ON LOT U CITY USE OF DISTRICT N . GROUP. + MAP PROCESSED BY BUILDINGS •� - ' BK PG t . CONTRACTOR • �. ADDRESS CONNECTION DATA> CITY TEL. NO. STATION �.� 0 i DEPTH 6- I STATE LIC MANHOLE REFERENCE �-. C lJ UPPER LICENSENO;: GLASS LOWE _ i NO. .DESCRIPTION OF WORK' FEE TYPE OFC TION LENGTH ROM P d HOUSE SEWER CONNECTING TO Y. .CURB P.L. M.L.TO P.L. PUBLIC SEWER @ $5.00 O P. . CNO. SEPTIC TANK.SEEPAGE PIT OR JOB NO. U PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. 17:1-761 O PRIVATE DISPOSAL SYSTEM @ S3.00 CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER E4SENENT RECORD.INSTR.NO. DATE WORK TO HOUSE SEWER @ S3.DO W OVERFLOW SEEPAGE PIT.DRAINFIELD d. EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $5.00 N ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING z SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT PERMIT NO. INDUSTRIAL WASTE APPROVAL. OWNERS PERMIT $ 000 AUTHORIZATION I TOTAL FEE co CONNECTION CHARGE FEE CHARGES IHAVE AT THIS DATE A CONTRACT WITH THE HE NAMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC Ste/YE i7'SB APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS ^� DAY OF L 4�i 19_ ^ OWNER OR NEW HOUSE SEWER OWNERS'AG NT "'_VVVV '�//,A/ �p �' CONNECT ADDITIONAL vo V// /,.zy�/J . - BUILDINGOR WORK (� ADDRESS �f ate/�"✓`1/ //rr/PP" i , SEPTIC TANK,SEEP,PIT(S) ^ I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICAT N AND/OR DoRAINFIELD V AND STATE THAT THE•ABOVE IS CORRECT AND AGREE TO COMPLY - F A WITH ALL .COUNTY ORDINANCES AND STATE LAWS REGULATING .CESSPOOL F-1 DRYW ELL ❑ G� far �V PLUMBING AND SEWERS. 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 D ISP OSAL SYSTEM CALIFORNIA OR THAT I AM THE LEGAL OWNER-T AND INTEND TO DISCONNECT PLUG AND " RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PR,yOPPEERTY. ABANDON HOUSE SEWER SiOF APERMTTTEE TUREBACKFILL SEPTIC TANKS,❑ s• SEEP.PIT(S) ❑ CESSPOOLS VALIDATIO JACK R. ALLEN SUPERVISING MECHANICAL ENGINEER CK. M.O. CASH ' Lt7Lo 7,0'.1 °`i` -GOT 4 1. G.. D . 0- c