HomeMy Public PortalAbout6443 LOMA AVE_Sewer__ i
76A6420
H-689 9.59 APPLICATION, FOR PERMIT 1
!&
DIVISION OF BUILDING AND SAFETY SEWER SEWAGE DISPOSAL
Department of County Engineer U
County of Los Angeles BUILDING t/ 7 Z_3
WM.J. FOX, COUNTY ENGINEER _ ADDRESS ,
s� CASSATT D. GRIFFIN,SUPT OF BUILDING LOCALITY ,
FOR APPLICANT TO FILL IN NEAREST
CROSS ST. ,
LEGAL jj
�
DESCRIPTION LOT NO. _ / OWNER
BLOCK TRACT / 7J f MAIL
ADDRESS
/,�[ ).G� j•'t�C.-
SIZE OF LOT x /7/' / NOWOONBLOTS CITY TEL. NO Z-Z/
USE OF
_jBUILDINGS DISTRICT NO. GROUPMAP
570
^
CONTRACTOR f p
ADDRESS - �/`-"�( CONNECTION DATA
CITY TEL NO �J! (� / STATION ® DEPTH ,w
X70 STATE MANHOLE REFERENCE ® �Q-M
REGISTRATION NO. ❑ COUNTY QCT /y
NO. DESCRIPTION OF WORK FEE TYPE OF CONN LENGTH FROMHOUSE SEWER CONNECTING TO �1 Y CURB PUBLIC P L M L TO P L �®
PUBLIC SEWER Q $ 3 50 G/
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100 _
CONNECT ADDITIONAL BLDG. OR P C NO
WORK TO HOUSE SEWER 1 00 CO. IMP NO V JOB NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL YSTEM 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 00 INDUSTRIAL
CESSPOOL-DRYWELL
WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
s 1 00
OWNER'S
PERMIT CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE elO REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAIAED CON-
TRACTOR�TO CONNECT TH ABOVE,DESCRIBED EXISTING DWELLING APPROVALS. DATE INSPECTORS SIGNATURE
TO THE PUBLIC SE E c � NEW HOUSE SEWERA
SIGNED THIS DAY OF - 19,Ly
CONNECT ADDITIONAL
OWNER OR -
OWNERS AGEN �(_ BUILDING OR WORK
- SEPTIC TANK,SEEP, PITS)
ADDRESS - f - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ 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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA- THAT 1 #'M THE LEGAL OAF OF HE ABOVE ABANDON HOUSE SEWER
IgCgD R E ROPER BACKFILL SEPTIC TANKS❑ /ryy ,d
/(,�+ •SEEP. PITS) ❑ CESSPOOL - A`,r �f�
SIGNATURE ,
OF PERMITTEE
WILLIAM J. FOX.COUNTY ENGINEER VALIDATION R.A.WOOD. CHIEF PLBG. INSPECTOR
I �a 7 3 6 2 c`,nJUU?5 4 4.5 'u m