HomeMy Public PortalAbout6423 LOMA AVE_Sewer__ � S&E-663 12-54 A •■ L�OXY--9T B®E V �,�FO Y y Y ■ •O V� IT 1
-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 '
FOR APPLICANT TO FILL IN NEAREST'
CROSS ST.
LEGAL, 'n
DESCRIPTION LOT NO OWNER
BLOCK - TRACT MAIL
ADDRESS
r� NO OF BLDGS. � -
SIZE OF LOT / �/ NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT N.O, 1 GROUP MAP
BK PG
CONTRACTOR ,
ADDRESS CO�INNECTION DATA
CITY' TEL. NO. STATION Q DEPTH
ST TE MANHOLE REFERENCE
REGISTRATION .y/1//1 i ❑ COUNTY UPPER
TYPE OFRON CTIO ,� LENGTH FROM
NO. DESCRIPTION OF W R FEE Y C B /iPy�L '1 M L.TO P L.
HOUSE SEWER CONNECTING TO r�j
PUBLIC SEWER - t(y $ 3.50 __j 4j7
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
DISCONNECT AND ABANDON SEWER STATE ENCROAC ENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIPL CONDITIONS ONLY 2 00 CH
CONNECTION C GE FEE '
OWNERS PEFIB TT $ 1 00
AUTHORIZATION I TOTAL FEE 6770
REIMBU SEMENT FEE
TRACTORHAVE T TO CONNEC HIS DATE TTHEAABOVE DESCRIBED BED EXIISTINGCTED WITH THE HEREIN A DWELLING G APPROVALS• DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19- NEW HOUSE SEWER
OWNER OR �f/,1`�•t/ 7�yCp CONNECT ADDITIONAL
ry 'C..r�
OWNERS AGENT BUILDING OR WORK
�, SEPTIC TANK,SEEP, PIT(S)
ADDRESS - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL E3AND 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 DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER 0 HE ABOV ABANDON HOUSE SEWER '
DESCRRIBED//j��/F�J$IDENTI 1/PROP TY. BACKFILL SEPTIC TANKS El
�GNA�URE SEEP.PIT(S) ❑ CESSPOOLS
OF PERMITTEE - - )
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
BY . !&53 _8_7- JUL '7 4-.5J 0
DEPUTY A,--', jDEPUTY
BY _ BY
-® DEPUTY DEPUTY
DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
z COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING ? �J 'D c� CNEAREST
ROSS ST.
ADDRESS b> '7 •L
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO. c
NEAREST A S
CROSS ST.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL
ADDRESS q 2- 1 USE ZONE OCCUPANCY BK MAP PG
CITY % TEL.NO.
CONTRACTOR CO.IMP.N0.
ADDRESS JOB.N0.
CITY TELAO. TRUNK PERMIT NO.
STATE
REGISTRATION NO. COUNTY ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF BLDGS.
NOW ON LOT CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLICSEWER @ $ 3.50 RECEIPT NO. I DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 100
ALTER OR REPAIR EXISTING NO- I DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 I STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
Y. CURB P.L. M.L.TO P.L.
OWNERS PERMIT $ I 1 00
AUTHORIZATION TOTAL FEE I I -
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS-------------------DAY OF------------------..---_ ......19.. NEW HOUSE SEWER
OWNER OR 1 /� CONNECT ADDITIONAL
OWNERS AGEN� 1 -• _..... -BUILDING OR WORK
------------------
SEPTIC TANKSEEP.
ADDRESS-- .......
!�.....-....._............... AND/OR DRAINF ELD PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI. CESSPOOL❑ DRYWELL❑
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AHD STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE SEEP.PIT(S)E] CESSPOOLS E]
OFPERMITTEE-------.......................................................................
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