HomeMy Public PortalAbout6455 LOMA AVE_Sewer__ CE8063-62 APPLICATION FOR PERMIT
76A642D
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL LJ
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONBUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS S"S o " 0
COLEMAN W. JENKINS. SUPT. OF BUILDING
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSSST. !�/
DE71
SCRIPTION LOT NO. .�3 OWNER 14i O i�
MAIL
BLOCK TRACT .� ADDRESS R
94 C-
NO. OF BLDGS. �J y
SIZE OF LOT NOW ON LOT CITY t TEL. NO. 4
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS BK PG n
CONTRACTOR �, � �j � 9(f --
ADDRESS 7��z/ /� p o e/ ' yl to y� CONNECTION DATA
CITY 14 0(0 Pa TEL. NO. {/ 3 J �V STATION S DEPTH �e j
STATE (]r O LIC �" / UPPER
LICENSE NO:. 7 (� CLASS �'' MANHOLE EFEREN E
LOWER
NO. .DESCRIPTION OF WORK' FEE TYP OFCONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. ,� O
PUBLIC SEWER @ $5.00 00 P.C.NO,
SEPTIC TANK.SEEPAGE PIT OR JOB NO. (,J
PITS AND/OR DRAINFIELD @ $10.00 CO. IMP.NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. Im
PRIVATE DISPOSAL SYSTEM @ $3.00 O
/7 CONNECT ADDITIONAL BLDG.OR pp AFFIDAVIT WAIVER EASEMENT RECORD. INSTR.NO. DATE V
/ WORK TO NOOSE SEWER @ $3.00 ®y
lil
OVERFLOW SEEPAGE PIT.DRAINFIELD �
EXTN..CE SSPOOL.DRYWELL.MA NH OLE @ $5.00 N
ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING 6 y
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s s 00
AUTHORIZATION TOTAL FEE ® OO CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEyIE� � r Q' APPROVALS DAJE I CTOR'S IG ATURE
SIGNED THIS / D OF / / ) _( y„
OWNER OR NEW HOUSE SEWER zN
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I AVE READ THIS APPLICATION AND/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 ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DIS POSAL SYSTEM
CALIFORNIA OR THAT I AM THE L L OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOVE C B RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S) ❑ CESSPOOLS
VALIDATION Ac R: ALLEN
SUPERVISING CHANICAL ENGINEER
CK. M.O. CASH