HomeMy Public PortalAbout6234 LOMA AVE_Sewer__ D
6&E-683 11.55 APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL "
Department of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS 3
T) CASSATT D. GRIFFIN. SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS ST.
1
DELEGAL
SCRIPTION LOT N0. OWNER
MAIL
BLOCK TRACT '•" _ADDRESS
NO. OF BLDGS. CITY TEL. NO.
.SIZE OF LOT NOW ON LOT _
USE OF
UILDINGS DISTRICT NO. GROUP MAP ,
B
BK PG
CONTRACTOR
' T
ADDRESS 10 CONNECTION DATA.,. .-L ��-?��. i
a
O
STATION DEPTH
1 MANHOLE REFERENCE UPPER
❑ STATE LOWER
REGISTRATION NO. ❑ COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM /
PUBLIC SEWER @a $3.50 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.
I
EXTN.,CESSPOOL,DRYWELL,MAN HOLE @ $ 2.00 CO. IMP. NO. JOB NO.
I HOUSE SEWER CONNECTING TO
I PRIVATE DISPOSAL SYSTEM 1 $1.00 TRUNK PERMIT NO. ROAD PERMIT NO. - -
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
_WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $1.00 INDUSTRIAL
WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00 -
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19- CONNECT ADDITIONAL
OWNER OR _BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
_ADDRESS - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
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 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGF{,hTURE SEEP.PIT(S) ❑ CESSPOOLS
OF PERMITTEE
JOHN A. LAMBIE,COUNTY ENGINEER VALIDATION ROBERT A. WOOD,CHIEF PLBG. INSPECTOR
CK. Y.0. CASH