HomeMy Public PortalAbout6437 LOMA AVE_Sewer__ 76A642D APC LICATIO ,F®p � PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER��E�/AGE ®ISP®SAL.
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
CRO55 ST.
LEGAL
DESCRIPTION LOT N0. 40 OWNER ,
�
BLOCK TRACT/ _L MAIL - -
ADDRESS
NO OF BLDG
SIZE OF LOT NOW ON LOT , CITY TEL NO
USE OF
BUILDINGS DISTRICT NO, I GROUP - MAP
BK PG
CONTRACTOR chi IF `. ER�.utt co
ADDRESSK7 ' f=ayr!. CONNECTION DATA
CITY ^y�j)� 6
IFFIEI 1 0 TEL. NOpa J_rj STATION 3 �'� DEPTH
i-C B .L� Yti ❑ STATE .'{ m MANHOLE REFERENCE
REGISTRATION N0. AA sh ')pJ ❑ COUNTY 21°' LOWER
��'O�JJ ��� ��"" -TYPE OF CONNECTION LENGTH FROM
NO. DESCRIPTION OF WORK FEE t f 11 y __ P L M L TO P L ��®
-] HOUSE SEWER CONNECTING TOT
/ PUBLIC SEWER Q $ 3 50 [J
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR CO. IMP. NO. /� JOB. NO.
WORK TO HOUSE SEWER 1 00 ISn
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
_ PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT 00
AUTHORIZATION TOTAL FEE �1 REIMBURSEMENT FEE
TRACTORHAVE CONTNE TONTRTHEA ABODVEWDESCR BED EXISTINGlill THE HEREIN AMED DWELLIINGG/ APPROVALS Da,E INSPECTOR SSIGNATURE
TO THE PUB
SIGNED THIS
DAY OF NEW HOUSE SEWER .7
OWNER ORS CONNECT ADDITIONAL
OWNERS AGEN1,2 BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE 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 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 PROPE BACKFILL SEPTIC TANKS❑ r
SEEP:PIT(S) ❑ CESSPOOLS
SIGNATURE v OF PERMIITTEE112 -Z�&
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
._ICO 7 5 8 0 SEP- 6 4 6.5 0 �
BY BY
DEPUTY
,BY BY
® DEPUTY DEPUTY