HomeMy Public PortalAbout6448 LOMA AVE_Sewer__ 5&E-6D APPL.I�CATION ��.F'®R PERMIT1
5 8 642D 12.54
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
WA.J. FOX, COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALIT
FOR APPLICANT TO FILL IN NEAREST
_CROSS ST,
LEGAL
DESCRIPTION LOT NO OWNER
� r
BLOCK TRACT )rzMAIL
NO. OF BLDGS. ADDRESS
SIZE OF LOT NOW ON LOT CITY v TEL. NO.
USE OF
BUILDINGS
DISTRICT NO. I GROUP I MAP
CONTRACTOR i s+� BK PG
Q !t�' CC'S.pICW!'ftliRt�C3 �9--- �a
ADDRESS 41 0M rAyc CONNECTION DATA
CITY { oNlEBELL0 TEL. N?p I�_If111�1tt1 STATION/ � � DEPTH (y �
�dL 'LY'�'Lif ❑. STATE , MANHOLE REFERENCE .
REGISTRATION NO. 3,4a'V�� (STATE) [I COUNTY ter' _ LOWER
U f/ TYPE OF CONNECTIONLENGTH FROM
�I DESCRIPTION OF WORK FEE Y,----� �U" P.L. M.L.TO P.L. 411.
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q $ 3.50 t
HOUSE SEWER CONNECTING TO tr
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO. IMP. N0. JOB. NO.
WORK TO 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
DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR —
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
S PECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT $ 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
Ff1 �3'
TRACTOR TO DATE CONNECT THECTED ABOVEWITH THEDESCR DESCRIBEDEREIN EXISTING DWD CON.
ELLING G APPROVALS DATE INSPECTORS SIGNATURE'
TO THE PUBLIC SEWER _
NEW HOUSE SEWER
SIGNED THI DAY OF 19
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP, PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL[I DRYWELL❑
AIJD STATE THAT THE ABOVE IS CORRECT AIJD 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 ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE 'n
DESCRIBED RESIDENTIAL PROPE TY. BACKFILL SEPTIC TANKS❑ `[ J�j/`� � . v
SEEP. PIT(S) ❑ CESSPOOLS (%Jj (�
SIGNATURE
OF PERMITTEE 4
Ir
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
t��07 5 7 0 SEP 6 4 4.50 m
BY BY
DEPUTY DEPUTY
e,
BY By
® DEPUTY DEPUTY