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Home My Public Portal About6213 LOMA AVE_Sewer__ 5-65 76A6420 APPLICATION FOR PERMIT 9 76A 64 COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIG. County Engineer ADDREss / //^ COLE,MN W. JENKINS,Sup't. of Building LOCA LiTY ` NEAREST FOR APPLICANT TO FILL IN CROSS 5T. LEGAL. DESCRIPTION LOT NO. N© / OWNER MAIL BLOCK TRACT t.{O ADDRESS - D! NO. OF BLDGS. SIZE OF LOT NOW ON LOT CITY �1 TEL. .NO. USE OF P��_ DISTRICT NO. GROU MAP PROCESSED BY BUILDINGS 4 v /FiE� f , J 2 N3 y BK PG CONTRACT ADDRESS 73 CONNECTION DATA CIT" 4'51L. NO. G / STATION `` DEPTH ij LI CE NS -23(m, " 11C SSSS ,G 17-- J MANHOLE REFERENCE N0. 0 LOWER NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM / HOUSE SEWER CONNECTING TO Y. RB P.L. M.L.TO P.L. ., PUBLIC SEWER C $ 5.00 SEPTIC TANK,--SEEPAGE PIT OR O P.C.NO. a CO.IMP. NO. JOB NO. PITS AND/OR DRAINFIELD �� $1 0.00 / O HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM C $ 3.00 CONNECT ADDITIONAL BLDG. OR AFFIDAVIT WnlvEa eASEMe Mi RECORD.IN5TR.NO. ATE O WORK TO HOUSE SEWER C $ 3.00 H ALTER, REPAIR OR ABANDON HOUSE (� SEWER OR DISPOSAL SYS TF.M C $ 3.00 W Z�S-EE-PWGE—Pf�DR-AI N I-TE HWY. OR ST.WIDENING O. UVEHFH E%TN.,CESSPOOL., MANHOLE C $ 5.00 STATE ENCROACHMENT Z I PERCOLATION TEST C $ 5.OG PERMIT NO, INDUSTRIAL WASTE APPROVAL OWNER'S PERMIT $ 2 00 CHARGES � AUTHORIZATION TOTAL FEE O 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 TO THE PUBLIC SEWER. APPROVALS DATE INSPECT R?--NATURE SIGNED TFi15 DAY OF 19_ OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL ,J v BUILDING OR WORK ADDRESS ` SEPTIC TANK,SEEP,PIT.(S) / I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECTAND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ - IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR LIC ENSEDAS REQUIRED BY LOS A S UNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT 1 AM THE L AL OW OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABOV CRI D R NTIAL PROPERTY.. ABANDON HOUSE SEWER / SIGNATURE BACKFILL SEPTIC TANKS El /' C OF PERMITTEE 4/ SEEP,PITS) ❑ CESSPOOLS v ✓ VALIDATION `F CK. M.O. CASH JUL31 1 0 Q 7.0-0- V