HomeMy Public PortalAbout6224 LOMA AVE_Sewer__ 0A642 D o-az
7APPLICA:TIO FOR IPER 8T
78A 642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING /
JOHN A. LAMBIE, County Engineer ADDRESS (l/�/s `
WILLIAM A. JENSEN, Sup't of Building
LOCALITY _
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER �A
MAIL
BLOCK TRACT ADDRESS ,
NO OF BLDGS
SIZE OF LOT W ON LOT CITY .- TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSED' BUILDINGS
i B K
P.
BUILDINGS -
CONTRACTOR 1 1 _ �/ � �
ADDRESS /� (f 6C�1 -T� CONNECTION DATA
CITY TEL NO 6'Y
STATION DEPTH
STATE E ^ UPPER
REGISTRATION NO O �✓ COUNTY MANHOLE REFERENCE ` ` d
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM O
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L � V
PUBLIC SEWER @ 35 00
SEPTIC TANK,SEEPAGE PIT OR P C NO
SCO IMP NO JOB NO
FPITS AND�OR DRAINFIELD @
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT N
A $300
O/ W
PRIVATE DISPOSAL SYSTEM f3 00 _� LLLLLLJJJJ
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I *41VEN I EASEMENT RECORD INSTR NO DATE a
WORK TO HOUSE SEWER @ S300 Ny
OVERFLOW SEEPAGE PIT,DRAINFIELD L
EXTN,CESSPOOL,DRYWEIL.MANH.LE @ SS 00
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
CON N6CTION CHARGE FEE
AUTHORIZATION TOTAL FEE
1HAVE 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 INSP TOR'S SIGNATURE
SIGNED THIS D Y OF 19_
OWNER OR /J NEW-HOUSE SEWER
OWNERS AGENT •J��
CONNECT ADDITIONAL
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 CORRECT AND AGREE TO COMPLY
-WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT 1 AM PROPERLY RE ISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COON Y AND STATE OF SEWAGE DIS P OSAL SYSTEM -
CALIFORNIA OR THAT I AM THE LEGAL OWNER , AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, TH VE DESCRIBED SIDENTIA PROPERTY ABANDON HOUSE SEWER _
SIGNATURE ( �� BACKFILL SEPTIC TANKS ❑
OF PERM _ SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
M O CASH SUPERVISING MECHANICAL ENGINEER
CK
LA[;0 0 9 7 1-0 OCT 3 1 0 D 7.0 0�