HomeMy Public PortalAbout6417 LOMA AVE_Sewer__ )'76AG420 CATION ri■ ■ FO■ ! P E R L W 7 I T
5&E•663 12.54 1
LI
DIVISION OF BUILDING AND SAFETY -SEWER-SEWAGE DISPOSAL.
Department of County Engineer
County of Los Angeles BUILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS
• CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
7- 7
L2��_ _6
FOR APPLICANT TO FILL IN NEAREST 41V i^
CROSS ST. U
LEGAL
DESCRIPTION --LOT NO - OWNER
BLOCK TRACT'
MAIL I`- �
ADDRESS`:. r '
NO.OF BLDGS.
SIZE OF LOT NOW ON T CIT TEL.
USE OF 7/
! a]
BUILDINGS G/ DI RICT N G OU Pol MAP
�S BK PG
CONTRACTOR /V
ADDRE CONNECTION DATA JJ '
TEL STATION �¢ (� DEPTH C� y
Zr - y d� MANHOLE REFERENCE
REGISTRATION NO r ❑ COUNTY d7� UPPER
e7 TYPE OF CONNECTION LENGTH FROM
NO. DESCRIPTION OF WORK FEE _y_ OURS P L M L TO P L. [$�J
-PUBLIC
SEWER CONNECTING TO
PUBLIC SEWER Q $ 3 50
HOUSE SEWER CONNECTING !0
PRIVATE DISPOSAL SYSTEM 1 00 �} _
CONNECT ADDITIONAL BLDG. OR CO. IMP. NO. /sv / JOB NO
'WORK (O HOUSE SEWER 1 00 _
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM _ 1 00 PERMIT NO. /
SEPTIC TANK, SEEPAGE PIT OR
PIPS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
-SPECIAL CONDITIONS ONLY 2 00 CHARGES
_ CONNECTION CHARGE FEE -
OWNER'S PERMIT $ 1 00 f`
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE ff
I HAVE THIS DATECONTRACTED.WITH THE EREIN NA ED CON- r
TRACTOR TO CONNECT THE ABOVE D EXIST G DWELLING APPROVALS DATE INS ECTOR•S SIGNATURE
TO THE PUBLIC SEWE SIGNED THIS DAY OF 1 NEW HOUSE SEWER
OWNER " OR - _ -CONNECT-ADDITIONAL �, L
OWNERS GENT BUILDING OR WORK
- SEPTIC TANK, SEEP, PIT(S)
ADDRES AND/OR DRAINFIELD- -
I H Y A KN WLEDGE 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
LICENSED AS REQUIRED BY LOS ANGELES0 TY AND TE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE L 0 N R F VE ABANDON HOUSE SEWER
DESCRIBED RESIDE 1 L PROPERTY KFILL SEPTIC TANKS❑
SEEP. PIT(S) ❑ CESSPOOLS- -
SIGNATURE
OF PERMITTEE
WILLIAM J. FOX,COUNTY ENGINEER VALIDATION
.. Ua7689� SEP 4 4.50 t .
BY BY —
DEPUTY DEPUTY
BY By
® DEPUTY V - ` DEPUTY�-