HomeMy Public PortalAbout6246 LOMA AVE_Sewer__ C
CE808- APPLICATIONF'®E \ PERMIT 7
E808-e-se COUNTY OF LOS ANGELES .L
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING
- -
JOHN A. LAM M County Engineer ADDRESS
CASSATT D. GRIFFIN, Sup't of Building LOCALITY '
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEAL
DESCRIPTION LOT NO. OWNER f
BLOCK TRACT MAIL
Gt ADDRESS Y
40
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL.NO.
BUIUSELDINGS
OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
y—� BK PG
CONTRACTOR �✓j
ADDRESS �/ CONNECTION-DATA
CITY TEL.N0. _ C) STATION �`� DEPTH
STATE MANHOLE REFERENCE U R
REGISTRATION NO. COUNTY LOWER
No. . DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO '
PUBLIC SEWER @ $9.00
SEPTIC TANK,SEEPAGE PIT OR TYPE OF TION LENGTH FROM
PITS AND/OR DRAINFIELD Q $8.00 Y. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM $1.00 CO.IMP. NO. Z JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT N0.
WORK TO HOUSE SEWER @ $1.00
SEWER OR DISPOSAL SYSTEM HOUSE $1 00 STATE ENCROACHMENT
PERMIT NO.
- INDUSTRIAL _
_ WASTE APPROVAL °
CHARGES
Ow1mrs PERMIT $ y 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1HAVE 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.
SIGNED THIS-,Zd--DAY OF Ig-LI-D NEW HOUSE SEWER GG►! (� �'�4I.>rc�l��1
OWNER OR 7 1 CONNECT ADDITIONAL
OWNERS AGEN BUILDING OR WORK
SEPTIC TANK,SEEP,PIS)
ADDRESS TAND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ 'DRYWELL❑
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 LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR I AM THE LEGAL OWNER OF THE'ABOVE
DESCRIBED REST Nil PROP TY. BACKFILL SEPTIC TANKS❑ ZS�� rE�/G�
SEEP. PIT(S) El .CESSPOOLS CJ
SIGNATURE
OF PERMITTE
®r VALIDATION _ ROBERT A.WOOD
CK. M.p, CASR SLIPERVISIMG MECHANICAL ENGINEER
L o1 1 561 1"[" 23 ' 0 A- 5.U0 ` � .