HomeMy Public PortalAbout6228 LOMA AVE_Sewer__ E.6D89 11•SS
S& Al 0 LICA 11 C O9 V Y O PERMIT
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DIVISION OF BUILDING AND SAFETY - SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN, SUP'TOF BUILDING LOCALITYNEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL � OWNER
DESCRIPTION LOT NO -e 6
i
C-7 tZ
BLOCKTRACT 6 MAIL
ADDRESS lGP%
NO.OF BLDGS
SIZE OF LOT O NOW ON LOT r CITY L? EL. NO.
USE OF �,c DISTRICT NO. GROUPI t MAP
BUILDINGS w DISTRICT
BK PG
CONTRALTO � �
CONNECTION DATA
ADDRESS
CITY �r NO r1 MANHOLE REFERESTATIONNCE DEPTH 6 '
d [� UPPER
STATE 1-7 f J� 0 LOWER
REGISTRATION NO O 05f ❑ COUNTY "
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CTION LENGTH FROM
PUBLIC SEWER @ $3 50 Q Y' CURB P L M L.TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT, DRAINFIELD - P. C. NO,
EXTN ,CESSPOOL,DRYWELL,MANHOLE @ $2 00 CO IMP. NO. 10B NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO. ROAD PERMIT NO V
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TU HOUSE SEWER @ $1 00 J Q799 PERMIT NO. '
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT $ t 00 '
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HERE[[ MED CON- APPROVALS DATE INSPECTORS SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTI G DWELLING '
TO THE PUBLIC SLkER _ _ NEW HOUSE SEWER -�
SIGNED THIS DAY 0 19� CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGE N - SEPTIC TANK,SEEP, PIT(S)
ADDRESS ✓ AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION ."'
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYW ELL❑ _
WITH ALL COUNTY, ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY OS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I h THE LEGAL OW R OF THE ABO ABANDON HOUSE SEWER
DESCRIBED RESIDENTIA R ERTY BACKFILL SEPTIC TANKS
SIGNATURE SEEP PIT(S) ❑ CESSPOOL �r 4US,l tl ,r
OF PERMITTEE
JOHN A LAMBIE, COUNTY ENGINEER. VALID ATIO ROBERT A WOOD, CHIEF PLG INSPECTOR
4t CK N O GASH
Ln 19 4
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6&E-663 3-SS APPLICA'TIQN FOR PERMIT _ 1
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DMSION OF BUILDING AND SAFL,TY' SEINER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING fP.7 � A
ADDRESS C/C> ti
WM=��j
M.J. FOX, COUNTY ENGINEER T
CASSATT D.GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS s
LEGAL 0 G� �•f�
DESCRIPTION LOT NO, OWNER
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP
CONTRACTOR CO` 5 �
ADDRESS CONNECTION DATA
CITY TEL. NO. STATION DEPTH
❑ STATE MANHOLE REFERENCE UPPER
REGISTRATION NO ❑ COUNTY LOWER
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION ,LENGTH FROM
Y CURB P.L M L TO P L.
PUBLIC SEWER Q $ 3.50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100 _
CONNECT ADDITIONAL BLDG. OR P C NO
WORK TO HOUSE SEWER 1 00 CO. IMP NO JOB NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
OWNER'S
PERMIT $ DD CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE I I
REIMBURSEMENT FEE
TRACTORHAVE CONNECTDATE ONTRTHEA ABOVE DESCRIBED EXISTINGCTED WITH THE HEREIN A DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS -DAY OF 19- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL[IDRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ,ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER '
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS[I SEEP. PITS) E3 CESSPOOLS
❑
SIGNATURE
PERMITTEEa,V y E �
WILLIAM J.FOX,COUNTY ENGINEER VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR
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