HomeMy Public PortalAbout6251 LOMA AVE_Sewer__ CE808111_57 APPLICATION FOR PERMIT- . . ,
COUNTY OF LOS ANGELES _ SEWER-SEWAGE 'DISPOSAL",_
DEPARTMENT OF COUNTY,ENGINEER
BUII.DING AND SAFETY DIVISION BUILDINGLr
JOHN A. LAM M Count eer ADDRESS-
CASSAIT D. GRIFFIN. Sup t of Building
LOCALITY
FOR APPLICANT TO FILL IN CROS sT.
FDESCRIPTION
J
LOT NO. a(, - OWNER a �,MAIL
TRACT 10�� ADDRESS.✓. �-C�-e ?*, �^Z4 2 1l1y pNOW ONNO.OF BLOTS CITY TEL NO. / U� n /�_ 'OF
/.1, �4' C�-�•c_ O` DISTRICT NO. GROUP MAP
BK
ADDRESS q.��r- (may CONNECTION DATA
CITY _ �j/jTEL.NO. 0 ,Z STATION DEPTH
STATE
REGISTRATION lJ r�` COUNTY MANHOLE REFE l NC UPPER
.? ` LOWER
NQ DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 50
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
.. ,0
PITS AND/OR DRAINFIELD @ $3.00 Y. CURB P.Ll M.L.TO'P L. 17
OVERFLOW SEEPAGE PIT,DRAINFIELD - �1
EXTN ,CESSPOOL,DRYWELL,MANHOLE @ $2.00 _
HOUSE SEWER CONNECTING TO P.C NO.
PRIVATE DISPOSAL SYSTEM @ $1 00 CO. IMP NO JOB N-0.
ADDITIONALCONNECT BLDG.OR
WORK TO HOUSE SEWER @ $1.00
TRUNK PERMIT N0. ROAD PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE -
SEWER OR DISPOSAL SYSTEM @ $1.00 STATE ENCROACHMENT
PERMIT NO
_ INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE l 7 ➢ REIMBURSEMENT FEE 101m-I HAVE- DATE A CONTRACT-WITH THE-HEREIN -
TRACTORATO CIONNECT THE ABOVE DESCRIBED EXISTINGAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.-- — - _- - -- _ ./- ---
.- .- _ - -. _ _ _ _ .___ .-- _ -
S16NED THI DAY OF 19 NEW HOUSE SEWER
OWNER-OR - -- ` - - "CONNECT ADDITIONAL-- -� - n/��- /j•• '•-
OWNERS AGENT A BUILDING OR WORK !fJ fir' �!
AbDRESS' - '""'"T" "-- "' "' - - - ••SEPTIC TANK,SEEP,PIT-(S)--- -- - - - - _ n
'AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION �_.•� q -: '�
AND S_TATE_THAT_TH_E ABOVE IS CORRECT AND AGREE TO COMPLY- CESSPOOL,[:] DRYWELL❑ •— - - •- - - --- - - -- --
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
1 HEREBY-CERTIFY THAT' IMAM PROPERLY'REGISTERED-"AND%OR"SEWAGE-DISPOSAL SYSTEM -- -• -• •• �,
LICENSED AS REQUIRED BY LOS ANGELES OUNTY AND,STATE OF DISCONNECT PLUG AND
CALIFORNIA OR T .T_( AM_ TH EG _0 N R OF HE- ABOVE ABANDON HOUSE SEWER
DESCRIBED SID IAL PROPE TY BACKFILL SEPTIC TANKS ❑
SIGNATURE �/ i( SEEP PIT(S) ❑CESSPOOLS ❑
OF PERMI• E
OF - - - - - - ' VALIDATION F Y r -ROBERT�A WOOD—
CK m.o, cASH SUPERVISING MECHANICAL ENGINEER
--- - - - - -, a 7-2 8 9 DEC 8 10 --A
D
S&E-663 3.88 APPLICA'T'ION FOR PERMIT' 1
9&E-6
DIVISION OF BUILDING AND SAFETY SEWER----SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN, SUPT OF'SUILDINO LOCALITY
FOR APPLICANT TO FILL IN CROSS ST.LEGL '
DESCRIPTION LOT NO. ry� OWNER
BLOCK TRACT (�® 'MAIL
ADDRESS
NO 0 BLDGS. '
SIZE OF LOT NOW ON LOT ,CITY TEL. NO.
i
USE OF
BUILDINGS DISTRICT N0. I GROUP BK MAP PG
1 '
CONTRACTOR
CONNECTION DATA
ADDRESS //�� L
CITYLIP—
;7/
TEL.,N STATION 7 '�' ` V DEPTHy
`/ ❑ STATE MANHOLE REFERENCE I I D' OWER
REGISTRAifON No.
/ ❑ COUNTY 1
NO. DESCRIPTION OF WORK FEE -
HOUSE SEWER CONNECTING TO TYPE pNNECTION LENGTH FROM
Y /CURB\ P L M L TO P L
PUBLIC SEWER @ $ 3 50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 _
CONNECT ADDITIONAL BLDG. OR A n P C NO
WORK TO HOUSE SEWER 1 00 CO. IMP NO J �i JOB NO.
,ALTER OR REPAIR EXISTING /'/
SEWER OR DISPOSAL SYSTEM 1 00 'TRUNK PERMIT NO ROAD PERMIT NO Z�
DISCONNECT AND ABANDON SEWER - -T
AND/OR DISPOSAL SYSTEM 1.00 ESTATE ENCROACHMENTPERMIT NO
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD .00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT g 1 00
AUTHORIZATION I TOTAL FEE a REIMBURSEMENT FEE
I HAVE DATECN-
TRACTORTTOS CONNECT THEACTED ABOVEWITH DESCR BED EXISTINGTHE HEREINA MED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER _
ilt qn A i'I
SIGNED THIS NEW HOUSE SEWER DAY OF � 19- 11-6 / _ .�-z�.V,•fr
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD '
1 HEREBY ACKNOWLEDGE THA
NAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL C3AND 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 LEG OF THE BOVE ABANDON HOUSE SEWEP
DESCRIBED RESIDENTI ROPERTY BACKFILL SEPTIC TANKS❑
SEEP. PIT(S) C3CESSPOOLS)�, ��✓! ifJ
SIGNATURE }
OF PERMITTEE
WILLIAM J.FOX.COU ENGINEER VALIDATION R.'A.WOOD, CHIEF PLBG. INSPECTOR