HomeMy Public PortalAbout6442 LOMA AVE_Sewer__ 76A"642D -CE808-10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS 1 Q
LOCALITY G�r
FOR APPLICANT TO FILL IN
NEAREST o
CROSS ST
LEGAL 770DESCRIPTION LOT NO 7 OWNER / / (/
MAIL41BLOCK TRACT ADDRESS "
`. NO OF BLDGS .A
SIZE OF LOT Ga NOW ON LOT �� CITY 24
USE OF DISTR CT NO ROUP MAP OCESSED BY
BUILDINGS
j I SK MAP
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CONTRACTOR Qi's � ,C& L /V, / �
ADDRESS GD D �J r CONNECTION DATA W/•'—
CITYh�Z NO X
lye,a1 STATION DEPTH
STAT t yoe LIC U VV MANHOLE REFERENCE UPPER
LICENSE N C/ CLASS LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L MIL TOPIL
PUBLIC SEWER @ $7 00
PC NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND�OR DRAINFIELD ® fl0 00 CO IMP JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO 0L
PRIVATE DISPOSAL SYSTEM S300 0
CONNECT ADDITIONAL BLDG OR gFFIDA VIT WAIrKk I-EASEMENT TR CORD INSTR NO I DATE V
WORK TO HOUSE SEWER $300
OVERFLOW SEEPAGE PIT DRAINFIELD p[
EXTN CESSPOOL DRYWELL 0 $5 00 HWY OR ST WIDENING O
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT W
MANHOLE 0 $7 00 PERMIT NO 4.
INDUSTRIAL N
WASTE APPROVAL Z
OWNERS PERMIT 11 3 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'SSIGNATU E
SIGNED THIS DAY OF X19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SANA SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR
OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTE D AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES OUNTY STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I THE LEGAL ER DISCONNECT PLUG AND
RESIDE IN THE B DESCRIB ID TI OP R ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTE BACKFILL SEPTIC TANKS El ❑
S PITS) ❑ POOLS
VALID`ATI CK. M.0 CASH
.t�'� 0 8 1 1« -JAi�3 0 1 0 0 6.010 H
D
9&E-663 3-BB APPLICATION FOR PERMIT' _
8&H-8
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deportment 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
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAIL
ADDRESS
0 NO OF BLDGS.
SIZE OF LOT (Q�J/'r NOW ON LOT CITY TEL. NO. _
USE OF
BUILDINGS _ DIST NO. GROUP I MAP
BK PG
CONTRACTO /V - 90
ADDRESS CONNECTION DATA
CIT YTEL. NO STATION *9 7. 3 DEPTH 6s_
STATE MANHOLE REFERENCE /�y� S
El �p�±e
UPPER
REGISTRATION NO.�^ COUNTY ll// �Of
NO DESCRIPTION OF WORK FEE
TYPE OF CONNECT IpJl FROM
HOUSE SEWER CONNECTING TO Y. CURB 'p Ll M M L L TO TO P L. CK
PUBLIC SEWER Q $ 3 SO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR /��� P C NO.
WORK TO HOUSE SEWER 1 00 CO IMP NO. vJ JOB NO
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
OWNER'S PERMIT 11 00
AUTHORIZATION I TOTAL FEE J,Q REIMBURSEMENT FEE
TRACTORHAVE TTOS CONNECTDATE ONTRTHEAABOVECTED WDESCR BEDITH THE H EXISTING NAMED
DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY 19y NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL t�
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP. PIT(S)
ADDRES AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 READ THIS APPLICATION CESSPOOL[IDRYWELL❑
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 '
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY.
BACKFILL SEPTIC TANKS❑
SEEP. PIT(S) ❑ CESSPOOLS�j
SIGNATURE
OF PERMITTEE -
WILLIAM J. FOX,COUNTY ENGINEER t-� VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR
LG2 7 9 IZR ro14 4 450 , 10