HomeMy Public PortalAbout6411 LOMA AVE_Sewer__ 78A84YD -
APPLICATION FORPERMIT "
ceeos-e•sa COUNTY OF LOS ANGELES
• DEPARTMENT OF COUNTY ENGINEER SEW�ER= E DISPOSAL
-
BUMDING AND SAFETY DIVISION BUILDING
ADDRESS x�c
JOHN A. LAMBIE, County Engineer
CASSATT D. GRIFFIN, Sup't of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. '
LEGAL -
DESCRIPTION LOT NO. I�_�J� OWNER
BLOCK TRACT / �� MAIL' J �
_L/ ADDRESS•' A`�/
NO.OF BLDGS. 4/ /-7�
SIZE OF LOT NOW ON LOT CIT TEL.N0. �
USE OF
BUILDINGS" — DISTRICT NO. GROUP MAP PROCESSED BY
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CONTRACTOR BK- -pd
� % _ ( �
ADDRESS G o� CONNECTION DATA
CITY��&C N0. f�O C STATION DEPTH
,c ❑ STATE
REGISTRATION NO. MANHOLE REFERENC UPPER
�C• �� "l._— fl—en]3NTY LOWER
NO. _ DESCRIPTION OF WORK : FEE.
HOUSE SEWER CONNECTING TO -
PUBLIC SEWER @ $3.00 pE OF CONNECTION- L GTH FROM
SEPTIC
TS AND%OR_DRAINFGELDT OR @ $3.00 Y' CU P.L. M.L.TO P.L.
"OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C. N
PRIVATE DISPOSAL SYSTEM - @ $1.00 - CO.IMP.NO. JWNIO. .
/ CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. OAD MIT N0.�- �
SEWER OR DISPOSALBASYSTEM HOUSE @ $1 OO STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL -
WASTE APP AL
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE I 07D 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 PUB LIC.SEWE
�INEW HOUSE SEWER
SIGNED THIS AYkF 19—
OWNER ORCONNECT ADDITIONAL € d
OWNERS AGENT ��: BUILDING OR WORK
ADDRESS �� V ,y, SEPTIC TANK,SEEP, PITS) /
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT .1 HAVE'READ THIS APPL CATION
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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF .pgpNDONHOUSE SEWER.
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIL PROP BACKFILL SEPTIC TANKS❑
SIGNATURE G �� , // _ // SEEP.PITS) ❑ CESSPOOL
OF PERMITTE
®p
/`-VALIDATION . . ROBERTA,WOOD
rg,! K.p.. G"X j SUPERVISING MECHANICAL ENGINEER