HomeMy Public PortalAbout6404 LOMA AVE_Sewer__ ^i 76AE-663 12•S4 ■
6 8 E•66A LI MAT'®N ■ O■ • PERMIT
_ 1
DIVISION OF BUILDING AND SAFETY SEWER-S E E DISPOSAL
Deportment of County Engineer
`y County of Los Angeles FNEAR
v
WM.J. FOX, COUNTY ENGINEER
CASSATT D. GRIFFIN, SUPT OF BUILDING
FOR APPLICANT TO FILL IN J.
imsaw
LEGAL _
DESCRIPTION LOT NO OWN
BLOCK TRACT ° MAIL
ADDRESS.
N0. OF BLDGS.
SIZE OF LOT NOW ON LOT CI TEL
USE OF /�
BUILDINGS C, DISTR N0. GROUP MAP
• r BK PG
CONTRACTOR
ADDRESS CONNECTION DATA
STATION ,1.1 a- �-, DEPTH
[3-STATE a MANHOLE REFERENCE
REGISTRATION NO. //) /_ A ❑ COUNTY UPPER ¢g{AhC-R'
TYPE OF WNECTION LENGTH FROM ��O
NO. 'DESCRIPTION OF WORK FEE CYC �i8� P L. M L TO P L
HOUSE SEWER CONNECTING TO
PUBLIC
SEWER Qi $ 3 30 -
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG. OR CO. IMP. NO. � JOB NO
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING
_ SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO. ROAD PERMIT NO
DISCON N ECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO,
SEPTIC TANK, SEEPAGE PIT OR
_ PITS AMD/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT S 00
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
1 APPROVALS DATE INSPECTORSrSIGNATURE
HAVE-THIS DATE' CONTRACTED WITH THE HEREIN NAMED CON- -
TRACTOR TO CONNECT THE AB E DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER �A
NEW HOUSE SEWER Y d
SIGNED THIS Y OF 19�� _-�
OWNER 0 CONNECT ADDITIONAL-
-
OWNERS ENT BUILDING OR WORK
ADDRESS SEPTIC TANK, SEEP, PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL[IAND 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
IHEREBY 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 THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SEEP.PIT(S) ❑ CESSPOOLS X• lf''
SIGNATURE u
OF PERMITTEEEE
v
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
a BY .ACO 7 BYO 2 AUG 24 4 4.5 N
DEPUTY ,,,ttt�gq DEPUTY
BY By /� P �_
® DEPUTY ell � DEPUTY